Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0177, written 31 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 May 2023 |
|---|---|
| Reference | 2023-0177 |
| Deceased | Andrew Shambrook |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
John Adrian Gittins Senior Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW. CORONER 1 I am John Adrian Gittins, Senior Coroner for North Wales (East and Central) 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 the 28th of March 2022 I commenced an investigation into the death of Andrew John Shambrook (DOB 17.2.77 DOD 27.3.22). The investigation concluded at the end of the inquest on the 28th of April 2023. The cause of death was recorded as being due to 1(a) Hanging and the conclusion of the inquest was that of suicide. The evidence indicated that Mr Shambrook was under the care of the mental health services and that there had been a referral to the Home Treatment Team, however he did not meet their criteria for treatment. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are that Mr Shambrook took his own life by hanging on the 27th of March 2022. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed the following matter 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 MATTER OF CONCERN is as follows. – The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team 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. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th of July 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 Family of the Deceased and to the Chief Coroner. 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 Dated 31st May 2023 Signature Senior Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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.
Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG ---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG Dyddiad / Date: 26 July 2023 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Dear Mr Gittins, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Andrew John Shambrook I write in response to the Regulation 28 Report to Prevent Future Deaths dated 31 May 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Andrew Shambrook. I would like to begin by offering my deepest condolences to the family and friends of Mr Shambrook for their loss. In the Notice, you highlighted your concerns that the health board has no documented or robust policy in relation to decision making criteria and thereafter, future treatment and care pathways when a patient is referred to the Home Treatment Team (HTT). In response to the Notice, I requested our Mental Health and Learning Disability Division (MHLD) to carefully consider your concerns and provide details of their plans to make our services as safe as possible, taking into account the learning from the inquest. Firstly, I can confirm that there is an approved Home Treatment Team Operational Policy (MHLD 0035) that has been in use since April 2018. However, this operational policy has exceeded its review date and we are progressing this through the review and ratification process as a priority. The policy will be reviewed by a working group of key stakeholders, to include home treatment team managers and key clinicians, led by a senior manager. As part of the process of reviewing the Home Treatment Team Operational Policy, the reviewers will be provided with your comments and instructed to ensure that these are fully taken into account. Once the review is complete, the revised policy will be subject to a period of consultation and will then proceed through the ratification process. Progress on the review and ratification process will be monitored by the divisional policy and procedure development subgroup and any potential delays will be escalated to the divisional senior leadership Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk team. Assurance will be provided on a monthly basis to the corporate regulatory group. I expect this process to be complete by 31 January 2024 and I will be happy to share with you a copy of the refreshed policy at that time. As an interim measure, MHLD have provided an addendum to the policy to ensure the concerns noted at the inquest are addressed. The addendum to the Policy will be shared across MHLD to ensure that there is consistency across all areas and I have enclosed a copy of this for your reference. I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself and Mr Shambrook’s family are being addressed. We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to the family and friends of Mr Shambrook for their loss. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Executive Director of Public Health , Deputy Director of Quality
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