Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0187, written 17 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jun 2022 |
|---|---|
| Reference | 2022-0187 |
| Deceased | Margaret Stringer |
| Coroner | Tim Holloway |
| Coroner area | Blackpool and Fylde |
| Category | Suicide (from 2015) · Mental Health related deaths · Care Home Health related deaths |
| Organisation named | Lancashire & South Cumbria NHS Foundation Trust · Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Lancashire and South Cumbria NHS Foundation Trust; 1) 2) Blackpool Teaching Hospitals NHS Foundation Trust; 3) Lancashire County Council; 4) Nightingales Care Limited; and 5) CORONER Zion Care Limited. 1 I am Tim Holloway, Assistant Coroner for the coroner area of Blackpool & Fylde 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://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST Following referral to the Coroner’s Office on 12th October 2020, the Senior Coroner for the coroner area of Blackpool & Fylde commenced an investigation into the death of Margaret Florence Joyce Stringer, aged 81. The investigation concluded at the end of the inquest on 30th May 2022, the inquest having been heard before me. The conclusion of the inquest as to the medical cause of death was: 1a Hanging I reached a narrative conclusion, as follows: “Suicide, the Deceased having taken her own life, in part because appropriate precautions were not taken to prevent her from so doing in the circumstances that the information about her risk to herself which was conveyed to those caring for her was incomplete and the extent of the risk of her so doing and the context in which that risk may eventuate were not fully recognised. The Deceased’s suicide was contributed to by the return to her of the item which she used as a ligature when it had been identified that, for her own safety, she should not have it in her possession.” 4 CIRCUMSTANCES OF THE DEATH . The following determination as to how, when and where the Deceased came by her death was reached at the conclusion of the inquest: “Margaret Florence Joyce Stringer died between 18.35 hours and 19.00 hours on 10th October 2020 in the bathroom adjoining her room in Nightingales Nursing Home, 355a Norbreck Road, Cleveleys, Blackpool, FY5 1PB. Having been seen by a member of staff at around 18.35 hours on the evening of 10th October 2020, Mrs Stringer was left alone in her room. Thereafter she proceeded to . Mrs Stringer had been discharged to Nightingales Nursing Home on 24th September 2020 following an admission to The Harbour mental health hospital (‘The Harbour’) under section 2 of the Mental Health Act 1983 which had commenced on 15th April 2015, after receiving treatment at The Harbour as an involuntary patient under section 3 of the Mental Health Act 1983 from 12th May 2020 to 26th August 2020 and after receiving treatment as a voluntary patient thereafter to the point of her transfer to Blackpool Victoria Hospital on 6th September 2020. Margaret presented a high risk of suicide throughout. Mrs Stringer had suffered longstanding mental illness and, in the days preceding her death, there had been an apparent deterioration in her mental health. She took her own life, in part because appropriate precautions were not taken to prevent her from so doing in the circumstances that the information about her risk to herself which was conveyed to those caring for her was incomplete and the extent of the risk of her so doing and the context in which that risk may eventuate were not fully recognised. The Deceased’s suicide was contributed to by the return to her of the item which she used as a ligature when it had been identified that, for her own safety, she should not have it in her possession.” CORONER’S CONCERNS 5 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) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’) Whereas the court heard evidence that Nightingales would not accept another patient with an equivalent medical profile/history and that, should a resident within one of Nightingales’ homes require access to items to be restricted, they would be given 1:1 support pending a mental health assessment and discharge to a more appropriate facility, it was not possible for the home concerned to advise the court as to how and by whom the lead in question had been returned to Mrs Stringer. The concern arises that, in the case of a resident whose care requires access to items to be restricted, there should be a fail- safe, documented system, known to and implemented by staff, by which access to those items by the resident is prevented. In the circumstances that the possibility of a resident requiring such care may still arise, this concern exists notwithstanding the decisions now made. 2) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’) The court heard evidence as to the potential detrimental effects of isolation and loneliness in the elderly, including evidence from the court appointed expert that isolation can be very corrosive, that it is the single most potent causative risk factor for depression in the elderly and that it can have a very detrimental effect on a person’s mental state. There is a need for this to be known amongst staff. The concern arises as one member of staff gave (disputed) evidence that they had little or no training in such matters. 3) (Addressed to Lancashire and South Cumbria NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire County Council, Nightingales Care Limited and Zion Care Limited (the latter referred to collectively as ‘Nightingales’)) The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs Stringer’s risk of suicide. They included the following: i. The care coordinator should have requested that the acute hospital make a referral to the Mental Health Liaison Team for a review; ii. It would have been good practice for a further professionals meeting / CPA review to have taken place prior to formal discharge and no later than just after discharge to Nightingales and for the family to have been invited, to ensure that everyone was aware of the plan, that the family was aware of Mrs Stringer’s legal status and to discuss next steps in terms of liaison with other services; iii. There should have been greater professional curiosity and better communication at the time of transfer; iv. The Harbour mental health hospital’s RNNA should have been reviewed to determine whether it needed to be updated and it should have been updated if there was any different clinical information. Further self harm or suicidal ideation, if seen to be significant, should have given rise to a further RNNA; v. There had, in fact, been further indications of self harm and suicidal ideation and, in any event, of a wish to die, on 30th June 2020, in August 2020 and on 3rd September 2020 which were significant and should have been addressed in the information provided to Nightingales and had not been; vi. Mrs Stringer was discharged from The Harbour mental health hospital without an up-to-date Care Act Assessment and, in any event, taking into account the need for Mrs Stringer to be transferred to the acute hospital (which had been necessary), an up-to-date Care Act Assessment had not been completed during the period of her admission to the latter hospital; vii. The risk assessment should have been completed and provided to Nightingales; viii. A positive behaviour support plan should have been completed and provided to Nightingales; ix. A care plan, compliant with CPA Policy and Procedures Key Standard 10, which should have identified a suitable environment in which to manage Mrs Stringer’s risk, her needs and mental health and crisis and contingency planning, to cater for the event of a significant relapse in her mental health, should have been completed and provided to Nightingales; x. Risk behaviour should have been identified to Nightingales and context given, whereas that had not been the case in respect of certain behaviour, including the incident on 30th June 2020; xi. The care coordinator should have been better informed at the points of transfer and discharge; xii. There should have been more robust follow up by the care coordinator whilst Mrs Stringer was at the acute hospital; xiii. There had been no mental health service involvement between the 7-day follow up and 28th September 2020 or, if there had, it had not been recorded; xiv. During the COVID-19 pandemic, it was not possible for a manager to carry out a face-to-face assessment in the mental health hospital but no equivalent measure had been implemented; xv) Whereas it would have been helpful for Nightingales to have received the Continuing Healthcare Checklist, it had not been provided; xvi) Nightingales would have wished to see the risk of suicide referred to in the “Risks to the Service User” section of the FACE Overview Assessment; xvii) The court appointed expert had concerns about the accessibility of key information in the FACE Overview Assessment given the format of that document. Whereas the court heard evidence concerning subsequent, significant, purposeful, developments in practice, the matters listed above can be condensed into a single concern that there should be a comprehensive, cohesive, frictionless system for the timely collation (including from the family and/or other carers) and timely communication / transfer of sufficient, accessible information ((not, simply, risk assessments) pertaining to suicide risk in patients / service users / residents, by and between each of the service providers concerned. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you: 1) Lancashire and South Cumbria NHS Foundation Trust, 2) Blackpool Teaching Hospitals NHS Foundation Trust, 3) Lancashire County Council, 4) Nightingales Care Limited and 5) Zion Care Limited 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 12th August 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: 1) The family of Margaret Florence Joyce Stringer 2) Lancashire and South Cumbria NHS Foundation Trust; 3) Blackpool Teaching Hospitals NHS Foundation Trust; 4) Lancashire County Council; 5) Nightingales Care Limited / Zion Care Limited. I am also under a duty to send the Chief Coroner a copy of your response. 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 by the Chief Coroner. 9 17/06/2022 Signature: TR Holloway (signed electronically) Tim Holloway Assistant Coroner Blackpool & Fylde
3 responses 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.
RESPONSE OF LCC TO THE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS OF 17TH JUNE 2022 FOLLOWING THE INQUEST INTO THE DEATH OF M STRINGER 1. Regulation 29 of the Coroners (Investigations) Regulations 2013 provides; (3) The response to a report must contain— (a) details of any action that has been taken or which it is proposed will be taken by the person giving the response or any other person whether in response to the report or otherwise and set out a timetable of the action taken or proposed to be taken; or (b) an explanation as to why no action is proposed. 2. This is the response of LCC to the concerns raised by the Coroner at box 5 paragraph 3 of the report issued under Reg 28. 3. There are 17 subparagraphs which are answered in turn; i - not applicable to LCC; ii - in as far as this relates to LCC, Mrs Stringer was discharged to Nightingales “for assessment” and the family had been liaised with (A1303 of the bundle 18/9/20 at 16.04 and Dr ) and were aware of the plan; iii - LCC feel this is dealt with below; iv - n/a to LCC; v - the social worker had not been made aware of the incidents on 30th June 2020 or 3rd September 2020 so could not pass them on. In any event, the information provided to Nightingale was clear about the history and risk of self-harm. See below. vi - an Assessment was available at discharge and this was provided to Nightingale prior to them accepting Mrs Stringer. The social worker was not able to see Mrs Stringer in BVH due to Covid restrictions. The placement at Nightingale was “for assessment” (A1264); vii - the assessment of risk was included in the assessment document sent to Nightingales and this dealt with risk of self-harm and suicide (A1253). The environment to manage risk was felt appropriate in Dr opinion and Nightingale had information to develop a care plan (A1375) viii - n/a LCC; ix - n/a LCC; x - risk was identified in the relevant section of the overview document (A1253) and see (vii) above; xi - n/a to LCC; xii - n/a to LCC; xiii - n/a LCC; xiv - n/a to LCC; xv - n/a to LCC; xvi - this document was provided to Nightingales and noted by them. The Social Worker noted recorded providing this to Nightingales and having conversation via telephone about Mrs Stringer (A1302-4); xvii - the format of this document will be reviewed, but it has a clear heading “risk” with a subdivision re self-harm/injury described as “serious apparent risk” and details of risk setting out mental health deterioration and attempts to kill herself (A1253). The review is taking place in line with the adoption of a strength based approach framework which has started and is planned to be rolled out across all Adult Social Care teams within the next 18 months. The Local Authority would question the proportionality of using Reg 28 in respect of a detail such as the format of a particular document. 4. The Local Authority have reviewed the case again after receipt of the Reg 28 Report and consider that the conclusion of Dr is correct, in that there was adequate assessment and management of risk of suicide and that the placement at Nightingale was appropriate. There may be some details to correct (e.g. layout of Overview document) but having had that opportunity the Local Authority does not feel there is specific action arising from the Report of its own review of actions and procedure that needs rectifying to avoid a future death. To generally assist Lancashire and South Cumbria NHS Foundation Trust and Blackpool Teaching Hospitals NHS Foundation Trust in ensuring that their provision of information and systems at discharge are as effective as possible, LCC have agreed to meet with and will continue to work with the Trusts in the future. Signed… ………(signed electronically) Dated……2nd August 2022………………………….. Director of Adult Community Social Care Lancashire County Council
Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool Lancashire FY3 8NR 12th August 2022 Mr Tim Holloway Blackpool and Fylde Assistant Coroner Municipal Buildings Corporation Street Blackpool FY1 1GB Dear Mr Holloway Ref: Prevention of Future Deaths - Reg 28 MS I write in response to the joint Prevention of Future Deaths report that was issued following the conclusion of the inquest into the death of Mrs Margaret Florence Joyce Stringer which concluded on 30th May 2022. Due to the multi-organisational factors identified at inquest, you requested a formal response from Lancashire and South Cumbria NHS Foundation Trust (LSCFT), Blackpool Teaching Hospitals NHS Foundation Trust (BTHFT), Lancashire County Council (LCC), Nightingales Care Limited, and Zion Care Limited, to be provided by 12th August 2022. With reference to your specific concern that “there should be a comprehensive, cohesive, frictionless system for the timely collation (including from the family and/or other carers) and timely communication / transfer of sufficient, accessible information ((not, simply, risk assessments) pertaining to suicide risk in patients / service users / residents, by and between each of the service providers concerned”, the response from BTHFT is as follows. BTHFT is one of many acute hospitals across this region which will interface with LSCFT for inter-hospital referrals and transfers. Similarly, it will interface with a number of local authorities who are making s.117 arrangements for patients previously admitted to LSCFT. LCSFT also provides a Mental Health Liaison Team service for BTHFT patients. The Trust respectfully submits that any system or process change for the sufficient identification of suicide risk should originate in LSCFT for their patients, to be cascaded and embedded with Acute Trusts and Local Authorities in the region. RESEARCH MATTERS AND SAVES LIVES – TODAY’S RESEARCH IS TOMORROW’S CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care. We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you. In relation to BTHFT’s internal process and protocol for the management of patients admitted from a mental health facility, and/or in relation to the Trust’s contribution to the Mental Health Act (MHA) s. 117 aftercare arrangements (which are the primary responsibility of the local authority and Clinical Commissioning Group, there is nothing BTH would propose to change at this point. The expectation and standard practice is that in inter-hospital transfers, the transferring hospital should always provide the receiving hospital with key medical and mental health information, together with contact details for the referring clinician, for ongoing communication. The provided mental health information can then be included in the Registered Nursing Needs Assessment, in addition to the medical aspects, to feed into the MHA s.117 aftercare arrangements. I, as BTHFT’s Executive Medical Director, together with the Clinical Lead for Discharge Services and Interim Head of Legal Services, have attended a meeting with LSCFT, to consider whether expectations are aligned for the continuity and safety of communication and information sharing between our organisations. A further meeting is proposed in September, to include LCC. BTHFT has also been provided with a copy of a policy prepared by LSCFT; the Admission, Discharge and Transfer of Care Policy and Procedure, which provides LSCFT clinical staff with guidance on the admission, discharge, transfer and hand over of patients between wards, teams and services whether they are within LSCFT or other service/private providers. BTHFT will collaborate with LSCFT and LCC to examine this LSCFT policy, and the interface with Acute Trusts and Local Authorities. We will cascade to the Matron, ward manager and consultant groups, what is expected of the respective organisations; to ensure that all relevant information, including suicide risk, is known, managed and communicated. BTHFT and LSCFT had, in any event, commenced planning for integrated governance meetings. The Joint Mental Health Governance Committee will meet quarterly, with the first being held 15 September 2022, and the aims of those meetings has been agreed: To support the delivery and development of high quality care to patients with psychological and psychiatric needs within BTHFT, through operational governance of incidents, complaints, risks in relation to mental health act, patient experience data, outcomes, audit and quality improvement, education and training. To review and ensure safe and appropriate estates and facilities in order to meet the mental health needs of patients. To provide a forum for dialogue and collaborative working between LSCFT and BTHFT. I hope that my response provides you with the assurance that the Trust has taken your concerns very seriously, and that appropriate action is being taken to address your concerns; in order to ensure that suicide risk is thoroughly understood, managed and communicated in patient transfers. Yours sincerely Executive Medical Director
Your Ref: 2 September 2022 Blackpool Country Coroner's Court Coroner’s Office Blackpool Council PO Box 1066 Blackpool FY1 1GB BY EMAIL ONLY Dear Mr Holloway Our Client Re : Nightingales Care Limited : Inquest touching the death of Margaret Stringer We write in response to the Prevention of Future Deaths report dated 17th June 2022. We have taken instructions from our client and respond to the matters raised below. For the avoidance of doubt, we have mirrored the numbering used in HMC’s letter: 1. As per the evidence of , Nightingale’s is not a secure unit and a resident with a similar history to that of Ms Stringer would no longer be admitted to the Home. Should there be a concern in relation to a resident who was already admitted at the home, a system of 1:1 care would be implemented which would restrict access to any items. An urgent referral would therefore be arranged for assessment of the resident and the resident would be discharged to a more suitable placement/acute hospital. The concern raised should therefore not eventuate. 2. As demonstrated by the training records appended to the statement of , all staff receive training in order to facilitate and encourage communication and interaction with residents. There are numerous activities arranged at the Home and in addition family members are encouraged to visit. 3. Nightingale’s have reviewed their admissions process and developed a new pre-admissions checklist that has previously been provided to the Court. The checklist covers a variety of relevant assessments that need to be undertaken for each new resident before they are admitted. If the assessments are not provided for complex admissions then the Home Managers will not accept the prospective resident. Home Managers are best placed to assess new admissions and are aware of the criteria DAC Beachcroft Claims Ltd The Walbrook Building 25 Walbrook London EC4N 8AF UK (Sat Nav postcode: EC4N 8AH) email: DX 45 London/Chancery LN which allow them to accept and reject new admissions. Home Managers will also reject prospective residents should they believe that the Home is not the right fit for the individual and they are unable to admit them to provide the care that they require, this is particularly relevant if they have challenging behaviours or may upset the dynamic of the Home generally. The Home is also reliant on the referring placements to provide accurate and up to date information in conjunction with the correct documentation. At the time of Ms Stringer’s admission face to face meetings were hindered by Covid, however this is no longer such an issue. The new processes and checklists have been implemented as a failsafe to ensure that all information is received prior to admission; in the absence of the applicable documentation the admission will not take place. We trust the above responses address the issues raise. Should HMC have any further questions, please do not hesitate to contact us. Yours faithfully DAC Beachcroft Claims Ltd DAC Beachcroft Claims - DAC Beachcroft Claims Limited is a limited company registered in England and Wales (registration number 04218278) which is authorised and regulated by the Solicitors Regulation Authority (authorisation number 509760). A list of the directors is available for inspection at our registered office: Portwall Place, Portwall Lane, Bristol BS1 9HS, UK (Sat Nav postcode: BS1 6NA). Please read our DAC Beachcroft group privacy policy at www.dacbeachcroft.com. an international law firm part of DAC Beachcroft, Page 2 of 2
See every Prevention of Future Deaths report matching Lancashire & South Cumbria NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.