Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0225, written 16 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jul 2022 |
|---|---|
| Reference | 2022-0225 |
| Deceased | Thomas Smith |
| Coroner | Tom Stoate |
| Coroner area | Bedfordshire and Luton |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | East London 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.
02047-2020
Senior Coroner - Emma Whitting
Bedfordshire & Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1)
Chief Executive Officer, NHS England and NHS Improvement
, Chief Executive, East London NHS Foundation Trust (“ELFT”)
1
CORONER
I am Tom Stoate, Assistant Coroner for the area of Bedfordshire and Luton.
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
On 5 January 2021 an investigation was commenced into the death of Mr Thomas
Antony Smith (hereafter where relevant “Thomas”), aged 33. The investigation
concluded at the end of the inquest (held with a jury) on 1 April 2022. The conclusion of
the inquest was a narrative conclusion as follows:
“Thomas died of a drugs related death as a result of a series of serious failings in his
care”
4
CIRCUMSTANCES OF THE DEATH
The jury empanelled for this inquest found the circumstances of Mr Smith’s death to be
as follows:
“Thomas died in part due to serious failings in the care given to him on Coral Ward
during the night of 29th/30th December 2020 following a positive drugs test around
8:30pm on 29th December 2020.
Thomas was granted Section 17 accompanied leave to go into Luton in the afternoon of
29/12/20. Following a visit to a Post Office, Thomas visited a vape shop where he
, before returning to Coral Ward.
possibly obtained
##DW<<corAddress>>
Concerns in Thomas's presentation prompted a urine drugs test at 8:30pm which was
positive. Accordingly [sic] to ELFT policy, this should have triggered increased
observations of Thomas. This was not done.
Other serious failings were:
- Lack in knowledge of Trust staff relating to patients who had tested positive for drugs
- The level of observations on Thomas was not increased and were insufficient following
assessment of him by the duty on-call doctor around 11:20 on 29/12/20
- Signs of potential deterioration in Thomas were not identified
- Thomas’s presentation and unidentified material found in his room which may have
been illicit drugs at around 02:40 on 30/12/20, were not escalated to more senior
members of ward staff.
There was an admitted failure in starting CPR on Thomas for a period of approximately
2 minutes after he was found unresponsive in his room at approximately 07:34am on
30/12/20, although this failure did not cause or contribute to Thomas's death.
A possible cause contributing to Thomas's death was the visit to the vape shop on
escorted leave under Section 17 on the afternoon of the 29/12/20.”
The cause of Mr Smith’s death was determined to be:
Ia Aspiration of Gastric Contents
Ib
Ic
II Cardiac hypertrophy and Dilatation
misuse
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) Knowledge of the dangers of
mental health patient settings
in detained
There was evidence of steps having been taken by the ELFT at a local level to remedy
’ and
the apparent lack of knowledge amongst its staff regarding the dangers of
after Mr Smith’s death, including its own substance misuse
training and inviting local substance misuse charities back onto its wards to work with
its patients and staff as Covid restrictions lift.
Bedfordshire and Luton Coroner Service
There was, however, various evidence which suggested a lack of knowledge from ELFT
staff around
and it’s potentially fatal effects, including that several witnesses:
(i)
(ii)
Did not know what ‘
’ or
could look like;
Were unaware of how of a person under the influence of ‘
’ or
might present; and
(iii)
Had received no training on the dangers of ‘
’ or
There was some evidence that this might be a wider issue of concern, both locally and
nationally, than only with ELFT staff. In the event that is correct, this report is directed
to NHS England and NHS Improvement.
2) The system for assessing risks associated with s.17 leave
I was told that, when a staff member is escorting a service user out of the ward, there is
an expectation for that staff member to be aware of the location, general mental state
and wellbeing of the service user; and that a ‘mental state assessment’ should be
carried out on the ward prior to leave taking place, as a further safeguard once s.17
leave had been granted.
However, the evidence of the healthcare assistant who took Mr Smith out on leave, on
the occasion (29 December 2020) that the jury concluded it was possible that he was
able to buy the
the misuse of which caused his death, was that:
(i)
He would not necessarily read a patient’s RiO (electronic continuous) notes
before taking a patient out on leave;
(ii)
He had not read Mr Smith’s care plan before taking him on leave;
(iii)
(iv)
There had been no handover from other staff to him of Mr Smith’s
presentation on 28 December 2020 presentation (when he was suspected of
being ‘under the influence’ of a substance); and
Although he had read the form authorising Mr Smith’s leave (i.e., the s.17
form), that form – a statutory document – does not contain information
about particular risks posed to a patient by or when out on s.17 leave.
As a result of the above, this particular healthcare assistant was unaware that:
(i)
(ii)
(iii)
On 28 December 2020 Mr Smith had been suspected of being under the
influence of drugs;
Mr Smith’s care plan of 20 December 2020 set out as a ‘risk issue’ the fact
that “Thomas has a history of using illicit substances”; and
The care plan set out as an ‘intervention’ for Mr Smith: “Nursing staff to do
random urine drug screening and breathalysing upon return to the ward.”
Bedfordshire and Luton Coroner Service
The healthcare assistant therefore appears to have been in a position of escorting a
patient on leave without knowledge of a patient’s very recent potential drug-related
presentation, or of a specified intervention aimed at reducing the risk posed to that
patient by drugs as set out in his care plan.
There was, however, no suggestion in the evidence of any witness during Mr Smith’s
inquest that the situation in which the escorting healthcare assistant found himself
represented a failure to follow policy or expected procedure. In the event that this is
correct there appears to be a wider issue – and this Report is therefore directed to NHS
England and NHS Improvement.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 Monday 19th September 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 family of Mr Smith.
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
Tom Stoate
H.M. Assistant Coroner for the area of Bedfordshire and Luton
Dated: 16 May 2022
Bedfordshire and Luton Coroner Service
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.
Mr Tom Stoate, Assistant Coroner for Bedfordshire and Luton, The Court House, Woburn Street, Ampthill, Bedfordshire, MK45 2HX National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 18 November 2022 Dear Mr Stoate, Re: Regulation 28 Report to Prevent Future Deaths – Mr Thomas Antony Smith who died on 30 December 2020 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16 May 2022 concerning the death of Thomas Antony Smith on 30 December 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Thomas’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Thomas’s care have been listened to and reflected upon. Following the inquest, you raised concerns regarding; 1. Knowledge of the dangers of in detained mental health patient settings – including the evidence at the inquest which suggested a lack of knowledge from East London NHS Foundation Trust (“ELFT”) staff around and it’s potentially fatal effects, and the fact that this might be a wider issue of concern, both locally and nationally. 2. The system for assessing risks associated with s.17 leave – in particular, the healthcare assistant in question appears to have been in a position of escorting a patient on leave without knowledge of a patient’s very recent potential drug-related presentation, or of a specified intervention aimed at reducing the risk posed to that patient by drugs as set out in his care plan. NHS England acknowledge and share your concerns regarding knowledge of both locally and nationally, although it is not within NHS England’s remit to deliver this education as a commissioner. Provider organisations are responsible for providing staff with the relevant training, to ensure that they are aware of issues pertinent to their patient population. In this particular case, ELFT will be responsible for training and refreshing their employees on in detained mental health patient settings, and this is addressed further below. Since 2013, local drug & alcohol services, which are routinely provided by local councils, are able to provide training on ‘New Psychoactive Substances’ including . In addition, Public Health England (“PHE”) previously issued a toolkit for prison staff on New Psychoactive Substances in January 2017, which NHS England was signed up to (Link here). PHE also issued a toolkit for commissioners earlier on in November 2014 (Link here). Both of these toolkits have information that would help healthcare staff to look after individuals who have taken and provide advice on how to manage substance use within secure environments, from a clinical, psychosocial and regime perspective. The NHS England Regulation 28 Working Group will ensure that your Report and this response is shared with all regions, to pass onto individual integrated care systems (ICSs) which are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area for further learning and consideration. https://www.england.nhs.uk/integratedcare/what-is-integrated-care/ ELFT have shared their action plan with us relevant to your Report and have been able to facilitate and deliver training to staff on the ward, as well as senior staff within the organisation. They have engaged local drug and alcohol service providers to deliver training and awareness around spice. They have also ensured that staff are aware of the relevant policies, to ensure effective management of patients who are suspected to be intoxicated. is 17 Leave covered 1983 Section (https://www.legislation.gov.uk/ukpga/1983/20/section/17). With this serious incident, ELFT have revisited the issue of having a robust leave risk assessment prior to a service user accessing leave and have reiterated this to all staff (substantive and temporary) within Luton and Bedfordshire. the Mental Health Act respect by to All staff members are aware that pre-leave risk assessments must be communicated and agreed by the Nurse in charge prior to leave. Any concerns raised by staff members with regard to pre-leave risk assessments must be communicated to the Nurse in charge. Additionally, if the Nurse in charge identifies that they are not clinically confident with decision making around leave and feels out of their depth, they would be expected to escalate this to their Clinical Nurse Manager or Modern Matron. For out of hours leave, the Duty Senior Nurse (DSN) on site would be able to support with decision making. I would also like to provide further assurances on the national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Thomas, are shared across the NHS at both a national and regional level, and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director
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