Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0096, written 1 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Apr 2022 |
|---|---|
| Reference | 2022-0096 |
| Deceased | Yvonne Eaves |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| Category | Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
• Dr.
Medical Director
GMMH NHS Trust
Trust HQ,
Bury New Road,
Prestwich,
Manchester
M25 3BL
Copied for interest to:
•
•
• The CQC
– the deceased’s sister
- the deceased’s sister
1 CORONER
I am: Senior Coroner Nigel Meadows
Senior Coroner for Manchester City Area
HM Coroner’s Court and Office
Exchange Floor
The Royal Exchange Building
Cross Street
Manchester
M2 7EF
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.
3
INVESTIGATION and INQUEST
On the 4th March 2020 I commenced an investigation into the death of. The investigation
concluded on the 29th March 2022.
The Conclusion of the inquest was: Narrative Conclusion: The Deceased suffered from a
chronic mental disorder and serious self-neglect. After compulsory admission to
hospital under the Mental Health Act there was a gross failure to provide her with
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basic medical care which contributed to her death and it was possible that if she had
received that care and VTE prophylaxis treatment she would not have developed a
pulmonary thromboembolism and died.
4 CIRCUMSTANCES OF THE DEATH
The deceased suffered with mental health problems since childhood and was considered
originally to have a personality disorder. She was treated by mental health services for many
years and had several inpatient admissions some of which were compulsory. She was
eventually diagnosed with psychotic depression and was treated with antipsychotic and
antidepressant medication. In addition, she also required considerable support for day-to-
day living and had an above normal BMI caused by her antipsychotic medication.
In December 2019 and in January 2020 she was noted to be self-neglecting and only
partially engaging with mental health and primary care services. On the 8 January 2020 she
was visited by her care coordinator and a psychiatrist who was unfamiliar with her
background. She presented as being malodorous, dishevelled and with unwashed hair. Her
partner was present, and he was noted to be abrupt and hostile. No appropriate
safeguarding referrals had been made and no comprehensive MDT discussion took place.
On 15 January 2020 she was reviewed by a consultant psychiatrist who considered that she
did require an admission to hospital and had the capacity to consent to this is as a voluntary
patient but there was no available bed.
On 24 January 2020 she refused voluntary admission and a recommendation was made for
a section 2 MHA. However, there was no AMPH capacity to progress this, but she was
subsequently detained under the MHA on 27 January 2020 at Park House Psychiatric unit,
Manchester. On admission she was found to be significantly malodorous and have several
long-standing serious deep infected ulcers/wounds and had to be transferred to the acute
hospital for assessment and treatment. Her condition gradually improved and she was given
prophylactic venous thromboembolism (VTE) medication until she was medically fit enough
to be discharged back to the psychiatric unit on 12 February 2020.
Subsequently, on readmission despite discharge information from the acute hospital that she
had been treated with VTE Prophylaxis there was a failure to undertake a VTE risk
assessment in accordance with the detaining authorities’ policy/protocol despite her fulfilling
several trigger criteria. There was a failure to monitor her condition and make appropriate
records or an action/management plan. She did not have further mental capacity
assessments. On the 19 February 2020 she was detained under S. 3 MHA. On the morning
of 23 February 2020, she had a cardio-respiratory arrest and was resuscitated for a brief
period of time before being taken to the emergency department of North Manchester
General Hospital where further attempts at resuscitation proved unsuccessful and she was
pronounced dead. This was caused by her suffering a pulmonary thromboembolism.
The GMMH serious incident investigation failed to establish whether the Responsible
Clinician, Jr. Doctors or nursing staff were aware of the trusts VTE policy and if not, why not.
Furthermore, if they were aware of it why was it not complied with. Nor if there was an
awareness and compliance with the policy Trust wide. It also failed to identify, acknowledge
or apparently be aware of the death of a patient in 2016 from a VTE at Park House unit
which subsequently led to the amended and updated VTE policy being introduced which was
not complied with.
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The investigation failed to establish why no formal mental capacity assessments were
undertaken and recorded or why there was not a reassessment of the VTE risks. The
investigation failed to identify, acknowledge or apparently be aware of the death of
another patient in 2016 from a VTE at Park House unit which subsequently led to the
amended and updated VTE policy being introduced that should have been complied
with in relation to the deceased’s care.
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:
1. There was a lack of appropriate safeguarding review, Senior clinical oversight as well
as necessary MDT meetings and actions to be completed.
2. It did not appear that all permanent or locum clinical and nursing staff Trust wide
were aware of the VTE policy and how it should be implemented including initial
assessments and reassessments of the risks as well as consequent medical
management.
3. There was no regular audit of compliance with the VTE policy.
4. There was no training programme to ensure familiarity and compliance.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and 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 the 27th June 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 Interested Persons. I have also
sent it to organisations who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
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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: 1st April 2022 Mr Nigel Meadows
HM Senior Coroner
Manchester City Area
Signed:
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