Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0263, written 25 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Aug 2022 |
|---|---|
| Reference | 2022-0263 |
| Deceased | Yuksel Ismail |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Category | Road (Highways Safety) related deaths |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 CEO Bedford Hospitals NHS Foundation Trust 1 CORONER I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton Coroner Service 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 09 December 2021 I commenced an investigation into the death of Yuksel Bedri ISMAIL aged 23. The investigation concluded at the end of the inquest on 24 August 2022. The Narrative Conclusion of the inquest was that: After absconding from a nearby hospital, the Deceased was struck by an HGV on the M1 and suffered fatal injuries. 4 CIRCUMSTANCES OF THE DEATH Shortly before 19.30 hours on 28 November 2021, the Deceased was witnessed to run into the path of an oncoming HGV on the M1 motorway. Despite the driver of the HGV taking all possible avoiding action, the Deceased was struck by the front nearside of the HGV and was fatally injured; although, he was taken by paramedics to the Luton & Dunstable Hospital, his death was confirmed at 20.30 hours. He had been admitted to the Luton & Dunstable Hospital earlier that day after having been found in a vulnerable state and had been assessed by the Psychiatric Liaison Team as being psychotic, lacking in mental capacity, and in need of a MHA assessment. In view of his vulnerability, the Psychiatric Liaison Service staff had also requested the Accident and Emergency Staff to provide him with 1:1 observation as they were concerned about him leaving the hospital. Whilst still awaiting a full MHA assessment, shortly after 19.00 hours, he had been transferred by the same member of staff carrying out the 1:1 observation to a Ward but, during the transfer, had absconded and exited the hospital site heading towards the M1. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. The Court was told that an SI investigation had not been completed by the Trust in this case; however, the PEARL Meeting on 3 December 2021 acknowledged that "the current transfer policy needs reviewing...the transfer policy implemented around the mental health patients should be prioritised as there are risks involving patients and staff, all depending on the assessment of the patient". Despite this and ELFT's own SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) having highlighted the need for PLS staff to be involved in any decision regarding patients waiting for MHA assessment, or who may need to be conveyed to another area within the hospital site as 'such patients are high risk and often unpredictable', by the start of the Inquest held on 24 August 2022, there was no evidence of Bedford Hospitals NHS Trust's acceptance of the recommendations made. Whilst at lunchtime on the day of the Inquest itself, the Court was provided with a draft of a new Transfer Policy, this Policy still did not appear to have addressed the main issue: - Whilst it includes "Confused, disorientated, self-harming, suicidal or displaying erratic or aggressive behaviours" and "patients at risk of absconding" in the list of 'At risk' patients in Section 3, the needs of such patients are still not addressed in the Assessment Tool (Appendix 4) nor is the need for consultation with the PLS staff about any of the escort/transfer arrangements. 2. Although ELFT's SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) had highlighted that "There is a need for staff involved in transferring patients, including security staff, to have training in the exercise of the Mental Capacity Act to ensure that patients who are assessed as lacking capacity with identified risks to self are unable to leave the emergency department" and recommended that "training be provided to acute Trust colleagues on the application of the Mental Capacity Act, its use to restrain/prevent somebody leaving the department if they are deemed to lack capacity and there are concerns regarding their risk should they leave, and where the person has capacity but remains a risk to the themselves", there was no evidence before the Inquest of Bedford Hospitals NHS Trust's acknowledgment or consideration of this. Instead: - The Court heard from several Trust witnesses including a ED Sister, that they considered they had no powers to detain someone within the ED; - The statement provided to the Inquest by the ED Lead, Court along with notice that he would NOT be available to attend the Inquest even though at the PIRH the Court had made it clear that the witness providing evidence of relevant Trust Policy would need to attend the Inquest) appeared confused about the powers available: (provided to the Para 12 "Physical restraint is permitted in circumstances where the patient is confirmed to lack mental capacity and the restraint is necessary to preserve life or health and is proportionate to risk" Para 17 "Even if a single security officer had assisted with the transfer, they would be unable to physically restrain as the restraint policy specifies a minimum of two security officers are required for this and Mr Ismail was not subject to lawful DOLS at that point"; - PLS Staff stated that they have known of other patients leaving the ED whilst awaiting a MHA assessment 6 ACTION SHOULD BE TAKEN In my opinion 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 October 20, 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 Chief Executive ELFT - I have also sent it to PC who may find it useful or of interest. 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 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 Dated: 25/08/2022 Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Luton and Dunstable University Hospital
Lewsey Road
Luton
LU4 0DZ
Tel 01582 491166
www.bedfordshirehospitals.nhs.uk
20th October 2022
HM Senior Coroner
The Bedfordshire and Luton Coroner Service
The Court House
Woburn Street
Ampthill
MK45 2HK
Dear Mrs Whitting
Re: Yuksel Bedri Ismail – Regulation 28 Report to Prevent Future Deaths
I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued on
26th August 2022, following the Inquest into the death of Mr Ismail, which concluded on 24th
August 2022.
I would like to begin by extending my sincere condolences to the family of Mr Ismail for their
loss. I appreciate this will still be a very difficult time for the family.
In response to evidence heard at the Inquest you raised some concerns around the policy for
transferring patients within the hospital and also the knowledge of our Emergency Department
staff in respect of the powers available to them under the Mental Capacity Act 2005.
This letter sets out the Trust’s formal response.
We acknowledge that our SI decision panel, PEARL, did not declare this an SI. On reflection
we agree this was not the correct decision and have taken steps to ensure that in future
greater consideration as to investigation requirements is given to incidents of a similar
nature. The most appropriate criteria in this case would have been a joint investigation
between ELFT and BHFT, and we will take this learning forward for the future.
We note that at the SI decision panel, PEARL, whilst we did identify that immediate
improvements were required to our Transfer Policy, these had not been fully actioned by the
time of the inquest. For this we apologise and have included a copy of the revised policy.
The policy has been updated in collaboration with colleagues at ELFT and now more fully
addresses patient needs. We have added Section 4.7 around patient transfers for those
identified at risk of absconding, and Appendices 6, 7 and 8 now support this addition to the
policy.
Cont…..
Collaborative work between the Trust and ELFT will also be ongoing to ensure embedding of
protocols and increased safety when it is necessary for mental health patients to be
transferred.
In response to concerns regarding application of the Mental Capacity Act and restraint training,
the Emergency Department together with the Trust’s Safeguarding Team have worked with
colleagues at ELFT to review the current provision for staff in the Emergency Department.
This has led to amendments which include updates to MCA and restraint training for junior
doctors in the Emergency Department and monthly shared learning forums with the PLS and
the acute medicine team where particularly complex cases are also reviewed.
I hope that this response provides assurance to Mr Ismail’s family and to you that the Trust
has taken the learning from the Inquest very seriously and continues to improve its policies
and procedures, and has put in place measures to ensure safe and effective services.
Yours sincerely
Chief Executive Officer
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