Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0129, written 21 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Apr 2023 |
|---|---|
| Reference | 2023-0129 |
| Deceased | Amy Henderson |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Suicide (from 2015) |
| 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 THIS REPORT IS BEING SENT TO: 1. 2. Group 1 CORONER Chief Executive Officer of The Priory Chief Executive Officer if NHS England I am Caroline Topping assistant coroner, for the coroner area of Surrey. 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 An inquest into the death of Miss Amy Henderson was opened on the 26th April 2022 and resumed with a jury on the 6th February 2023. The inquest was concluded on the 23rd February 2023. Evidence in respect of matters pertaining to this report was heard on the 20th March 2023. The jury concluded that Miss Henderson died on the 21st March 2022 at the Priory Hospital, Woking and the medical cause of her death was: 1a Suspension They concluded with a narrative conclusion and found that: 1. The Priory staff knew Amy had suicidal ideation, but they did not know any details concerning plans, or that she had practised tying a ligature. 2. No-one at the Priory asked her family about her suicide plans. 3. It is not possible to determine what Amy would have said to her consultant if she had been asked about suicide plans. Amy denied having any plans when asked by an HCA and she denied having thoughts of suicide in her 1:1 with a SHCA. 4. If Amy’s mother had been asked, she would have shown the screen shots from Amy’s phone and given details of Amy practising tying ligatures. Amy’s mother has no recollection of volunteering the information. 5. Despite the notes from the therapy sessions being uploaded at 16.06, there was no formal request for Amy to be reviewed. There is evidence from professionals that Amy should have been reviewed urgently on the basis of the notes, if they had been scrutinised. 6. If information about Amy practising tying a ligature had been known, there would have been more consideration given bearing in mind the balance of risk and least restrictive practice. 1 21st March. Amy was generally compliant with staff, 7. After the identification of the disabled toilet as a high-risk area in 2021, the ligature risk of the disabled toilet was not effectively managed although the Priory considered that it was. 8. Amy had unrestricted access to the disabled toilet, which was accessible to all patients, staff and visitors. 9. The Jury was not able to make a finding as to whether Amy was alive between 19.35 and 19.47. . In summary the following facts, on the balance of probabilities, made a material contribution to Amy Henderson’s death: a. Risk Assessments were not performed in line with Priory policy. b. There was no Key Worker present throughout Amy’s stay. c. There were incomplete observations and little evidence of engagement with Amy during observations. Boxes were not ticked on Observation and Engagement Records. d. The family was not consulted or questioned about Amy’s Suicide Plans. e. Therapy notes were not acted upon. f. There was a lack of staff training in Postnatal depression. g. There was a lack of continuity of care. h. The disabled toilet was not locked. i. Staff knowledge of the ligature footprint was inconsistent. Amy committed suicide. She used a herself. She is shown on CCTV entering the disabled toilet and no-one else entered it until Amy’s body was discovered. The death was contributed to by Neglect ligature and intended to kill 4 CIRCUMSTANCES OF THE DEATH Miss Henderson had a baby in 2021. When her baby was 11 months old she returned to work, but was signed off sick suffering from anxiety and depression. On the evening of the 14th March 2022 she was taken by her family to Kingston Hospital and assessed by the liaison psychiatric team. She expressed suicidal thoughts and plans She was diagnosed with post partum depression. She was advised to become an informal patient in the NHS but there was no bed available so she would have had to wait in the hospital until a bed could be found. She decided to seek a private admission the following day. On the 15th March 2022 she sought treatment at the Priory Hospital, a consultant Woking. She had a preadmission assessment with psychiatrist who accepted her as a patient. She told him that she had a suicide plan but did not provide details of what it was. He assessed her as a high risk of suicide and set observations at four times an hour. She was allocated a Key Worker who was not due to be in the hospital until 22nd March 2022, and a Co-worker, who had a one-to-one with her on 19th March 2022. Her overall mental health appeared to have improved when on March 18th 2022. The observation level she was reviewed by was reduced to twice an hour on the 16th March 2022, and then further to 2 once an hour on the morning of March 21st 2022, on each occasion without a risk assessment being performed as specified in the Priory policy. Later on the morning of the 21st March 2022 Miss Henderson made comments during a therapy session which indicated that her mental health was deteriorating. The therapists recorded what she had said in her notes, but the concerns were not considered to be serious enough to be escalated to the nursing team. Evidence presented to the inquest suggests that Amy’s observations should have been increased at this stage. Amy was not reviewed by the nursing team when the therapists’ notes were uploaded onto the system at 16.06 on 21st March 2022. The information was not reviewed and therefore not acted upon. Miss Henderson was last seen in person at 18.02 in the dining room. At 18.12. she entered the downstairs disabled toilet. The disabled toilet had been identified in risk assessments as a high-risk area but it was not locked. She wrote a farewell note to her parents at 18.14. She was found in the disabled toilet on the ground floor at 20.01. She had taken her own life by suspension, 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 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: 1. The information that Miss Henderson had practised tying a ligature was divulged by her at Kingston Hospital but not repeated on admission to the Priory Woking. The evidence given at the inquest was that there is no quick method to obtain NHS records on admission to a private hospital. A request could have been made but the records would have taken over a week to be released. The records were not sought. An ability to obtain the NHS records quickly would have been of assistance to the Priory clinicians. 2. The Priory Woking has a policy in relation to the removal of banned and restricted items but there was a lack of clarity and confusion among the clinicians as to who was responsible for ensuring that such items are identified and removed from the patient at admission. 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. 3 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th June 2023. 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: Miss Henderson’s family The Priory Woking The Care Quality Commission 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. 9 Caroline Topping, 21st April 2023 4
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 Caroline Topping
HM Coroner’s Court
Station Approach
Woking
GU22 7AP
Dear Coroner
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
14 June 2023
Re: Regulation 28 Report to Prevent Future Deaths – Amy Henderson who died
on 21 March 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 April
2023 concerning the death of Amy Henderson on 21 March 2022. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Amy’s family and loved ones. NHS England are keen to assure
the family and the coroner that the concerns raised about Amy’s care have been
listened to and reflected upon.
In your report, you raised a concern that there was no quick method to obtain NHS
records on admission to a private hospital. It is hoped that improvement will be made
to issues such as this through the NHS England Shared Care Records programme,
which seeks to bring together information from a range of healthcare providers in
support of the provision of direct care. The focus is on the person receiving the care,
rather than the provider and supports the safe and secure sharing of individuals’ health
and care information. A shared care record joins up information based on the
individual, from across different organisations. For patients, shared care records will
include information such as care plans, previous appointments, inpatient stays, clinical
contacts and medications, and is anticipated to bring:
• Safer, more coordinated services
• Reduction in time by avoiding the need to repeat medical or social care
history
• Fewer repeats of tests, appointments and admissions
• Preferences and needs observed
•
•
Improved experience and continuity of care
Improved confidence in services
Implementation and operation of shared care records is the responsibility of Integrated
Care Boards (ICBs). Initially, public sector connectivity is being prioritised but the
forward programme plan for the Shared Care Record programme for 2023/25
acknowledges the important role that independent sector providers of care play. NHS
England are aware that some ICBs are already engaging with Voluntary, Community
and Social Enterprise organisations, recognising the important role that they play in
the provision of care to their population. The Shared Care Record programme is also
prioritising national interoperability, pertinent to this case where there were two
separate Care Record locations (South West London ICB, where Kingston Hospital is
located, being part of the London Care Record, and Surrey Heartlands ICB, where this
site of the Priory is located, being covered by the Surrey Care Record). Further
information on the Shared Care Record programme can be found here.
Regarding your second concern that at The Priory Woking there was a lack of clarity
and confusion among clinicians as to who was responsible for ensuring that banned
and restricted items are identified and removed from a patient at admission, this is
outside of NHS England’s remit and I note that you have also addressed your Report
to Priory Group who are the appropriate organisation to respond to this concern.
NHS England has, however, been sighted on Priory Group’s Serious Incident Report
regarding this matter and the resulting Action Plan and recommendations. I would like
to provide some additional assurance that national guidance around risk assessments
is currently being reviewed. I have also asked my regional colleagues to confirm
whether Priory Woking now has access to GP records. NHS England is happy to
provide further updates to the coroner in due course.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national
and regional level and helps us 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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