Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0048, written 15 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Feb 2022 |
|---|---|
| Reference | 2022-0048 |
| Deceased | Jason Lennon |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Other related deaths |
| Organisation named | East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MR G IRVINE
ACTING SENIOR CORONER
EAST LONDON CORONERS SERVICE
ADULT LEARNING COLLEGE, 127 RIPPLE ROAD, BARKING, IG11 7PB
Telephone 020 8496 5000 Email coroners@walthamforest .gov.uk
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Ministerial Correspondence and Public Enquiries Unit
Department of Health and Social Care, 39 Victoria Street. London, SW1 H
0EU
Trust, 9 Alie St, London E1 SOE
, Chief Executive, ELFT, East London Foundation NHS
Board, NHS England,
, National Medical Director, The National Quality
1
CORONER
I am Graeme Irvine, acting senior coroner, for the coroner area of East London
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.
http:LLwww.legislation.gov.ukLukpgaL2009L25Lschedu1eLSLg_aragraphL7
httg_:LLwww.legislation .gov.ukLuksiL2013L1629LpartL7 Lmade
3
INVESTIGATION and INQUEST
On 31 st July 2019 Ms Nadia Persaud opened an investigation touching upon the death
of Mr Jason Lennon, a man aged 37 years old .
1
Ms Persaud opened an inquest on 15th August 2019 , the inquest was heard , before a
jury commencing on 17th January 2022 and concluding on 11 th February 2022.
The conclusion provided by the jury was a narrative conclusion arrived at through a
questionnaire .
The Jury made the following conclusions;
•
Failures in Jason's community mental health care contributed to his
death ,
• Restraint used by security officers at the Excel centre contributed to
Jason's death,
• Although the use of restraint by the security officers was necessary, the
extent and manner of that restraint was unreasonable, specifically; the
level of force used, the location of the restraint - on the floor, Jason's
position - prone , and finally , the duration of that restraint.
The medical cause of death was found to be;
1.a. Cardiorespiratory Arrest in association with Restraint and Acute Psychotic
Episode
4
CIRCUMSTANCES OF THE DEATH
Jason Lennon was a 37-year-old man who lived in supported accommodation , he had a
medical history of; anoxic brain inju ry and enduring schizophrenic illness. Mr Lennon
had a history of periodic relapse resulting in acute psychosis and an associated
increased risk of harm to self and others, these relapses resulted in periods of
involuntary inpatient treatment under Mental Health Act section .
On 28th July 2019 Mr Lennon assaulted another resident at his accommodation, support
staff assessed that Jason was in re lapse, he was delusional, agitated and paranoid .
Support staff reported the incident to the police and the local mental health services, the
East London Foundation NHS Trust ("ELFT") Community Recovery Team ("CRT") , a
drop-in review was arranged at the CRT offices on 29/7/19.
Nursing staff at the CRT undertook a review of Mr Lennon, the patient left the meeting
prior to its conclusion. The CRT assessed that Jason's mental state was stable and he
was not in crisis.
On 31 st July 2019 Mr Lennon left his accommodation at 06.55hrs and proceeded to
Prince Regent's Lane. A total of 13 separate 999 calls were made to the police over the
next 35 minutes reporting Jason's conduct. The calls described Mr Lennon acting in an
unusual and confrontational manner, assaulting bystanders and walking into traffic.
Police officers responding to these calls were directed to the Excel Centre. Jason had
entered the premises as a trespasser, pursuing a member of the public at 07.29 and had
been restrained by security staff at the venue.
Officers found Mr Lennon at 07 .35 , on the floor, being restrained in a prone position by a
number of security officers. Jason was found to be unresponsive, checks made found
him not to be breathing , no pulse could be located . Cardio-pulmonary resuscitation was
commenced and very swiftly, the London Ambulance service attended. Advanced Life
Support was commenced and Jason was transferred to hospital. Treatment continued at
the hospital , however at 09 .31 further resuscitative efforts were deemed futile and life
2
was pronounced extinct.
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 could occur unless action is taken . In the
circumstances it is my statutory duty to report to you .
The MATTERS OF CONCERN are as follows . -
1. Expert psychiatric evidence indicated that Mr Lennon was a suitable candidate
for the Care Programme Approach mental health pathway and that the use of
this pathway would have reduced the risk of an acute deterioration in his mental
state . The CRT failed to effectively monitor whether Mr Lennon was on a care
pathway appropriate to his needs.
2. The CRT undertook a flawed review of Mr Lennon's mental state on 29/7/19
which failed to assess that, Jason was in relapse and was a risk of harm to
himself and others.
Factors which contributed to this failure included ;
a. CRT staff did not effectively review medical records prior to assessing
Jason,
b. The CRT did not communicate important clinical information between
themselves and external stakeholders,
c. The CRT did not adequately document important information arising from
the assessment.
3. The Trust undertook a serious incident investigation report into the events
leading to Mr Lennon's death in November 2019 which made a series of
recommendations
to have been
incomplete by 6/2/22 due to errors attributable to the Trust's governance team .
for action . The action plan was
found
4. Accepted individual failings by staff within the CRT fall below standards set by
their regulator. There is no evidence before the court to assess whether ELFT
have considered the necessity to make a referral to a regulator.
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 13th April 2022. 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 following Interested
Persons the family of Mr Lennon, the CQC and The Nursing and Midwifery Council. I
have also sent it to the local director of Public Health who may find it useful or of
interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all
3
interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it
useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary
form . 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 .
9
[DATE] 15/02/2022
[SIGNED BY CORONER]
~N~ N. Persaud, Area Coroner
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