Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2022-0005, written 31 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Dec 2021 |
|---|---|
| Reference | 2022-0005 |
| Deceased | Maziellie Mackenzie |
| Coroner | Philip Holden |
| Coroner area | Lancashire and Blackburn with Darwen |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Lancashire & South Cumbria NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Lancashire and South Cumbria NHS Foundation Trust 2. Family of Maziellie MacKenzie 1 CORONER I am Philip Holden Assistant Coroner, for the coroner area of Lancashire and Blackburn with Darwen. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] 3 INVESTIGATION and INQUEST I commenced an investigation into the death of Maziellie MacKenzie. The investigation concluded at the end of the inquest on 01st November 2021. The conclusion of the inquest was A) Narrative conclusion. B) Short f orm conclusion - Suicide 1 4 CIRCUMSTANCES OF THE DEATH:- Maziellie Mackenzie (‘MM’) was a looked after child and had been under the care of Cumbria County Council since 2016. She had a history of Mental Health issues and had been diagnosed with PTSD, Attachment Disorder, Anxiety and Depression. Following a number of foster and residential placements which had broken down she had been placed in a tier 4 hospital catering for young people with Mental Health issues between the ages of 13 and 18 at the Cove Heysham and had been there since the 29/05/18. She had a history of self harm which started initially with in the Cove there were several incidents of . Whilst On the 23/06/18 she went on a third period of leave that day with 3 other residents and 2 members of staff to a . At the end of the leave all residents including Maisie refused to return to the Cove. One member of staff was able to persuade one of the residents to return with her. The other member of staff followed two of the other residents who made off in a different direction to MM. MM was discovered a few hours later by a group of youths in a despite CPR an attending paramedic confirmed her death at 23 03 hours. She took her own life and a subsequent note found in her room at the Cove evidenced her intention to do so. In the Narrative conclusion failings at the Cove were identified in that :- 1. 2. Formulation and risk management plans were not revisited when self-harm incidents occurred and did not include Mazie’s needs and how they were to be met. Her risk assessment held limited risk history and management plans in regard to Mazie's risk of going missing. 3. There was no written standardised procedure for agreeing and facilitating leave. 4. Communication of relevant inf ormation and record-keeping did not meet the required standard. 5. There were insuf ficient staff members with the 4 residents who were on leave. 2 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – [BRIEF SUMMARY OF MATTERS OF CONCERN] Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out :- (1) The circumstances in which group leave from the Cove ( and other tier 4 units) is granted and who is responsible for the granting of such leave. (2) That a mandatory risk assessment is required and setting out a list of f actors/criteria that must be considered before any group leave is granted. (3) Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by [DATE]. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family of Maziellie MacKenzie. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary f orm. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 [DATE] 31/12/21 Philip Holden 4
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
PRIVATE AND CONFIDENTIAL Mr Philip Holden Assistant Coroner Safety Department Lancashire & South Cumbria NHS Foundation Trust 2nd Floor Lingmell House Water Street Chorley PR7 1EE 21 February 2022 Dear Mr Holden Re: Prevention of Future Death Report Following Inquest into the Death of Maziellie MacKenzie Further to the inquest of Maziellie MacKenzie, which concluded on 15 December 2021, I am providing you with a response to your concerns detailed in the Prevention of Regulation 28 Notice, dated 31 December 2021. Please be assured the Trust has taken this extremely seriously. We are disappointed that we did not deliver care and treatment to the level expected for Maziellie at the time of her death and I reiterate the Trust’s apologies regarding this. I hope my response provides you with the assurance that we have implemented improvements that prevents similar incidents from occurring. The circumstances in which group leave from the Cove (and other tier 4 units) 1. is granted and who is responsible for the granting of such leave. The Trust have developed a written procedure (enclosed), which identifies the circumstances in which group leave from The Cove is granted. The Cove is the only Tier 4 CAMHS unit within the Trust. The procedure was approved at the Specialist Network Governance Group on 3 February 2022 and has been subsequently shared with staff. Until the procedure was ratified, group leave at The Cove was temporarily suspended, following receipt of your Regulation 28 notification. Whilst the procedure has been shared with staff, there are further engagement events planned, which includes ensuring every member of staff has this discussed with them as part of their supervision and also ensuring that this procedure is part of the unit’s induction programme, so this is highlighted to new starters also in the unit going forward. That a mandatory risk assessment is required and setting out a list of 2. factors/criteria that must be considered before any group leave is granted. The enclosed procedure (section 5.15) sets out that young people with approved escorted group leave must have a pre-leave risk assessment completed prior and documented as a narrative entry on RIO (the Trust’s clinical record system). This is to make sure that any potential risks or changes in a young person’s presentation are acknowledged and so that the necessary safeguards are put in place. The procedure states that “risk assessment should consider the presenting level of risk and the care plan (including the number of escorts where identified).” Prior to the risk assessment being completed, any period of group leave must be discussed and agreed by the multi-disciplinary (MDT) meeting and be included as part of each individualised care plan and have an identified therapeutic purpose. The MDT discussion should capture the risk mitigation factors and the risk aggravating factors in relation to the mix of the group, irrespective of the legal status of the young person. The procedure also identifies that young people will only be eligible for group leave if they are being nursed on general observation levels and any change in observation that occurs after the decision to grant group leave, but before the planned group leave will result in the individual being unable to access group leave. The procedure also includes that an individual young person’s participation in the MDT agreed group leave can be cancelled by the shift leader if there are concerns about individual or group risks which were not previously known or have changed since the decision was made by the MDT. In the event a young person does not agree to the conditions of group leave, the individual’s participation in the intervention should be reviewed by the shift leader, in conjunction with the MDT as necessary. Setting out the staff to patient ratios for any group leave and identifying the 3. criteria to be considered. The procedure specifies that the MDT must agree in advance on the specific staffing requirements to safely support a period of group leave and this should be based on the combined dependency needs of individuals in the group. In the event that the required staffing levels cannot be achieved, leave should be cancelled and an incident form completed. The mandated pre-leave risk assessment is also to include the number of escorts needed. We have shared this procedure with other North West of England Tier 4 CAMHS providers, in the interests of shared learning. The Trust would like to once again apologise to the family of Miss MacKenzie for her tragic death. I would also like to re-affirm our commitment as a Trust, to continually develop and improve our services for the young people in Lancashire. Please let me know if you require any further information in relation to this matter. Yours sincerely Chief Improvement and Compliance Officer Enc
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