Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0231, written 26 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 | 26 Jul 2022 |
|---|---|
| Reference | 2022-0231 |
| Deceased | Archi Johnson |
| Coroner | Alison Longhorn |
| Coroner area | Exeter and Greater Devon |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Organisation named | Devon Partnership NHS 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.
Her Majesty's Senior Coroner for Exeter and Greater Devon
Philip Spinney
26 July 2022
Case ref: 311092
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Devon Partnership NHS Trust
Wonford House
Dryden Road
Exeter
EX2 5AF
CORONER
I am Alison Longhorn Area Coroner for the coroner area of Exeter and Greater Devon
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
INVESTIGATION and INQUEST
On 14th November 2019 I commenced an investigation into the death of Archi Johnson.
The investigation concluded at the end of the inquest on 11th May 2022.
The conclusion of the inquest was suicide, the medical cause of death being hanging.
Exeter and Greater Devon , County Hall, Topsham Road, Exeter, Devon, EX2 4QD
CIRCUMSTANCES OF THE DEATH
Archi was diagnosed with Schizoaffective Disorder with a history of depression,
self-harm and suicidal ideation. On 5th November 2019 Archi was voluntarily admitted
into Moorland View at North Devon District Hospital having told mental health professionals
that he had intrusive thoughts of taking his own life and he did not feel safe to go home.
During an admission on the ward two months earlier, Archi had attempted to take his own life
by ligaturing
On admission, Archi’s risk level was assessed as medium and he was placed on
Level 1 observations.
On 7th November 2019 Archi was found hanging
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.Evidence was heard regarding the manner in which information crucial to the
formulation of risk assessments was recorded and shared:
a)Two types of risk assessments were completed, with no system to ensure that important
information is present on both;
b) The previous incident in which Archi had attempted to take his own life in very similar
circumstances on the ward was not clearly entered on the risk assessments used by staff
and therefore not known to a number of those responsible for his care;
c) Those responsible for his care accepted that the above incident was one of which they
would have wanted to have knowledge;
d) The absence of that information may have affected the subsequent decisions made
regarding the setting of risk level, observation level and removal of potentially
dangerous ligature items.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that your organisation
has the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely
by 23rd 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.
Exeter and Greater Devon , County Hall, Topsham Road, Exeter, Devon, EX2 4QD
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to Archi’s Family.
I am also under a duty to send a copy of your response to the Chief Coroner and all
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 by the Chief Coroner.
26 July 2022
Signed:
Alison Longhorn
Area Coroner
Exeter and Greater Devon
Exeter and Greater Devon , County Hall, Topsham Road, Exeter, Devon, EX2 4QD
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.
Ms Alison Longhorn
Area Coroner
Exeter and Greater Devon Coroner’s Office
Room 226
Devon County Hall
Exeter
EX2 4QD
Trust Headquarters
Wonford House Hospital
Dryden Road
Exeter
EX2 5AF
Web: www.devonpartnership.nhs.uk
Your Ref: 311092
Our Ref: 2019.24496-RMS 60127
20 September 2022
Dear Ms Longhorn
Re: Archi Johnson - Inquest 11 May 2022
Regulation 28 Report to Prevent Future Deaths
Thank you for your letter following the inquest into the death of Archi Johnson. As an
organisation we are committed to learning from these tragic events and have since receiving
your report and recommendations taken the opportunity to share your findings with the service
involved as well as across the wider trust.
The Trust has undertaken a Serious Incident Investigation following the death of Archi; the
report was shared at the inquest and I can confirm that the action plan developed in response
to the RCA investigation has been completed.
Your report contained the following matters of concern -
1) Evidence was heard regarding the manner in which information crucial to the formulation
of risk assessments was recorded and shared:
a) Two types of risk assessment were completed, with no system to ensure that important
information is present in both
b) The previous incident in which Archi had attempted to his own life in very similar
circumstances on the ward was not clearly entered on the risk assessments used by
the staff and therefore not known to a number of those responsible for his care
c) Those responsible for his care accepted that the above incident was one which they
would have wanted to have knowledge
d) The absence of that information may have affected the subsequent decisions made
regarding the setting of risk level, observation level and removal of potentially
dangerous ligature items
We have attached a copy of the actions we have taken or continue to progress to ensure that
lessons are learnt from this tragic death. I hope that the actions described demonstrate our
commitment to the learning we have undertaken and that the Trust is committed to this
continued positive work within our services. If you require any further information please do
not hesitate to contact me.
As you may be aware, the Trust is currently experiencing issues accessing our usual electronic
patient record systems and as a result there may be some delays in completing the actions
relating to the clinical audit as this will depend on our being able to access the full clinical
records. We continue to support people who use our services and the Trust is able to maintain
current records using a secure alternative. We are working closely with the software provider
to resolve these technical issues and apologise for any delay that may result.
Yours sincerely
Executive Director of Nursing and Professions
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