Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0070, written 4 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2022 |
|---|---|
| Reference | 2022-0070 |
| Deceased | Sarah-Louise Doyle |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Mersey Care 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 (2) NOTE: This form is to be used before an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mersey Care NHS Foundation Trust 2a Oakhouse Park, Liverpool L9 1EP 2. The family of Sarah –Louise 3. Merseyside Police 4. The Chief Coroner 1 CORONER I am Andre REBELLO, Coroner for the area of Liverpool & Wirral 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. INVESTIGATION 3 On 04/03/2022 I commenced an investigation into the death of Sarah-Louise Jennifer Doyle, aged 19. The investigation has not yet concluded and the inquest has not yet been heard. 4 CIRCUMSTANCES OF THE DEATH Sarah Louise Doyle was 19 years old with a history of emotionally unstable personality disorder and anorexia personal eating disorder. She was detained under Section3 MHA. She had been a patient on Harrington ward since 15th November 2021 and was moved to Clock View, Alt Ward on 16th December 2021. On Saturday 26th February 2022 at 21.00pm a support worker took over responsibility for completing checks on patients as a result of their risk assessment. Sarah was on 5-minute observations due to a risk of ligaturing. During the 5 minute checks on there were no incidents of note. At 21:25pm the support worker went into Sarah's room where she was sat on the bed, replied she was ok when asked and support worker left the room and closed the door. On checking at 21:30pm support worker could not see her sat on her bed so went into her and found Sarah hanging . The support worker ran out of the room and requested assistance from colleagues who managed to remove ligature and commence CPR until paramedics arrived and took over. She was taken to Aintree Hospital and sadly despite best efforts her death was pronounced at 01.40am 27th February 2022. An article 2 investigation has been commenced and the Forensic postmortem result from the 3rd March 2022 is awaited pending special examination including toxicology. 5 CORONER’S CONCERNS 1 During the course of the investigation my inquiries 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. – On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations. The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations. 6 ACTION SHOULD BE TAKEN In my opinion urgent 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 29/04/2022. 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 Sarah-Louise’s mother and Merseyside police. 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 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 by the Chief Coroner. 9 [DATE] [SIGNED BY CORONER] 04/03/2022 2
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.
Date: 27th April 2022 Mersey Care NHS Foundation Trust V7 Building Kings Business Park Prescot, Merseyside L34 1PJ Dear Mr Rebello, Re: Sarah Louise Doyle (deceased) Regulation 28 Report dated 4 March 2022 I write under Regulation 29 in response to your Regulation 28 Report dated 4 March 2022 in relation to concerns arising out of the death of Sarah Louise Doyle, 5 days earlier, on 27 February 2022. The inquest has not yet been listed. The Trust always takes the death of any service users seriously and is keen to learn lessons where possible. I can confirm that your report has already been shared in the Trust Wide Executive Safety Huddle which is attended by Trust Executives and representatives from each clinical Division and also via Divisional Safety Huddle meetings. Safety Huddles are weekly meetings held at both a Trust Wide and Divisional level and have in attendance clinical and other professional managers from each service area. The purpose of the meetings is to highlight any new safety issues, incident trends or immediate learning to be shared. The concern you identified in your report was that the five minute observations of Sarah were recorded exactly on each five minute interval and that these observations were covered by one signature with a downward arrow. I can confirm that in relation to supportive observations the following actions are already either complete or well underway: 1. Urgent instructions have already been given via the Associate Director of Nursing and Patient Experience as to the use of and recording of intermittent observations, which is in addition to the Trust Supportive Observation Policy. 2. On March the 8th 2022 the Regulation 28 was discussed at the local division safety huddle with all inpatient Matrons present. An immediate action was for them to discuss with their respective ward managers the need to ensure changes in the language used to describe level 2 observations to support more accurate recording. The discussions confirmed intermittent observations should take place within each 5, 10 or 15 minute ‘windows’, rather than saying that they are 5, 10 or 15 min checks (as they won’t be taking place at exactly those timed intervals). 3. A further Senior Leadership Team meeting was held on 14th March 2022 to ensure oversight of what was required and timescales for completion. The Inpatient Matrons were given until 25th March 2022 to ensure the changes in recording of observations to unpredictable times was rolled about and discussions held across all staff groups in each inpatient ward. This has been completed. 4. A local audit has been developed with Inpatient Matrons to check and provide assurance that recording the actual time service users were checked is taking place, as opposed to rounding to the nearest 5-minute time window. As additional assurance, spot checks are being undertaken by the Senior Leadership Team and Inpatient Matron/ Ward Manager group. 5. Inpatient Multi Disciplinary teams have been reminded that if it is deemed clinically appropriate for a service user to remain on 5-minute unpredictable times, that a clear rationale is given in the clinical notes as to why this is required and not a full level 3 one to one observation. Ward Managers and Inpatient Matrons are overseeing this. 6. Inpatient staff are required to have yearly competence assessments regarding supportive observations. All of the staff on the wards in Clock View will have had their yearly competency updated on the supportive observation policy and will have been observed in practice carrying out at least 2 supportive observations checks by the end of April 2022. All of the other wards across Local Division will be completed by the end of May 2022. 7. The Senior Leadership Team, Inpatient Matrons and Ward Managers have carried out spot checks on supportive observation forms and immediately challenge poor/inaccurate record keeping. Inpatient Matrons are also doing extra “dip audits” on observations records to specifically review the timings of supportive observations to ensure these are random within the time ‘window’ rather than specific to the 5 minutes. 8. It is part of the role for the Nurse in Charge of each shift to carry out random checks of documents and the ward environment throughout the shift. 9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings. I hope that this letter assists in explaining the actions that the Trust have already taken in the immediate period following Sarah’s sad death to address the specific concerns raised in your report. I can confirm that the Trust is in the process of carrying out a review into Sarah’s death and will share this report with you as well as actions proposed and taken as a result of it. A number of wider actions have already been commenced on a trust wide footprint which can be shared at the future inquest hearing. Dr Consultant Forensic Psychiatrist Deputy Chief Medical Officer – Patient Safety and Quality Director of Patient Safety
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