Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0322, written 8 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Sep 2023 |
|---|---|
| Reference | 2023-0322 |
| Deceased | Lynsey Smalley |
| Coroner | Kate Robertson |
| Coroner area | North West Wales |
| Category | Other 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.
Kate Robertson Senior Coroner for North West Wales REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Betsi Cadwaladr University Health Board (BCUHB) 1 CORONER I am Kate Robertson, HM Senior Coroner for North West Wales 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 18 May 2021 I commenced an investigation into the death of Lynsey Sarah Smalley (DOB 6/3/79) who died on 16 May 2021. The investigation concluded at the end of the inquest on 7 September 2023. A narrative conclusion was recorded with the cause of death as:- 1a Septic Shock 1b Airway burns with inhalation injury On the 8th April 2021, Lynsey Sarah Smalley deliberately set fire to her bed at her home address during an acute psychotic episode. The smoke from the fire caused inhalation injury which led to her admission to the Intensive Care Unit at Ysbyty Gwynedd, Bangor. Lynsey Sarah Smalley remained in the intensive care unit for several weeks with poor respiratory progress. She did not recover from her injuries and died at Ysbyty Gwynedd, Bangor on 16th May 2021. Given her psychotic episode it cannot be said that she intended to end her life by causing the fire. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- The deceased was aged 42 at the time of her death on 16 May 2021. She had a past medical history of mixed schitzotypal and emotionally unstable personality disorder with traits of Asperger’s syndrome. She had mobility difficulties and required a bariatric bed due to concerns regarding skin integrity. She lived at home with her brother who cared for her. Lynsey Smalley was known to the Community Mental Health Team (CMHT) since 2005 and had a Care Coordinator who was a Community Psychiatric nurse. She was also open to a Psychiatrist and an Occupational therapist. On 6 April Coroner's Office, Shirehall Street, Caernarfon 2021 the CMHT were contacted by Lynsey’s brother who was concerned that Lynsey was acting strangely. A second call was made by her brother with concerns that Lynsey had relapsed and was displaying signs of paranoia, auditory and olfactory hallucinations, irritability, poor sleep and isolating herself in a particular room. A further call was made with reported concerns that Lynsey was lighting candles, had not used her prescribed oxygen and had not been eating, drinking, or sleeping for the past 4 days. It was indicated that there were only certain professionals Lynsey would agree to see but that she had agreed to see the care coordinator the following day. The GP prescribed medication and Lynsey’s brother was advised to contact Police if the situation became difficult. There was a total of 4 calls made by Lynsey’s brother to the out of hours crisis team. In addition, Lynsey’s brother contacted the emergency services for assistance. Police officers attended and a CID16 was completed and sent to the CMHT the following morning. By 9.10am on that same morning the CMHT reviewed the out of hours report. The care coordinator arrived at L’s home at 10.30am. Lynsey was reluctant to engage, and her brother reported concerns including that Lynsey had not slept for several nights, was not eating or drinking. He reported the incident overnight where Police had attended. The Care coordinator returned to the office and discussed with a psychiatrist, who agreed to visit that same day and the Advanced MH practitioner to assess and consider admission. After approximately 10 minutes of the care coordinator leaving Lynsey ignited a fire in the property. Emergency services were contacted. Lynsey was taken to Ysbyty Gwynedd, Bangor where she remained until she passed away on 16th May 2021. 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 – a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence. One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes. Furthermore, there were a number of proposed actions which took nearly two years to identify and complete. The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into the future. b. A number of individuals and organisations are involved in the care of those under mental health teams or at times have contact with patients e.g. CMHT, Home Treatment Teams, Psychiatrists, Occupational therapists, Care Coroner's Office, Shirehall Street, Caernarfon Coordinators, out of hours crisis service (local authority based in Gwynedd), Police, Ambulance Service etc. As medical records remain paper based not all individuals or organisations who need to understand a patient’s circumstances/care/treatment are privy to all aspects of care/treatment. In addition, where a CMHT patient is receiving in-patient mental heath treatment the paper notes are transferred to the hospital setting. There is a risk that notes will become lost in full / in part. Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes. I have previously issued a Prevention of Future Deaths Report on this point, a copy of which was also sent to Minister. , Health 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 3 November 2023. I, Kate Robertson, 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 have also sent a copy of this Report to information. , Health Minister, for her 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 8 September 2023 Signature Kate Robertson HM Senior Coroner for North West Wales Coroner's Office, Shirehall Street, Caernarfon
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
Kate Robertson
Senior Coroner for North West Wales
HM Coroner’s Office
Shirehall Street
Caernarfon
Gwynedd LL55 1SH
Dyddiad / Date: 30 October 2023
Dear Ms Robertson,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Lynsey Sarah Smalley
I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 08
September 2023, issued by yourself to Betsi Cadwaladr University Health Board,
following the inquest touching upon the death of Ms Lynsey Smalley.
I would like to begin with offering my deepest condolences to the family and friends of Ms
Smalley.
In the notice, you highlighted your concerns that there were three investigation reports
into the care and treatment provided to Ms Smalley and the length of time it took to
propose actions for improvement and complete said actions.
In response to the Notice, I asked our Mental Health and Learning Disabilities Division
(MHLD) to consider your concerns and provide details of their plans to ensure timely
progression of investigations and action plans.
The MHLD Division have reviewed the investigation reports for Ms Smalley and I have
listed these below in date order for ease of reference:
On 09 August 2021, an initial investigation report into the care and treatment provided to
Ms Smalley was shared with the Coroner’s office. The author of this report was Iolo
Jones. The reference for the report is INC258782. The report was finalised on 26 May
2021.
On 27 January 2022, the Health Board received a complaint (reference COM52706) from
Mr Andrew Smalley raising concerns about the care and treatment of Ms Smalley. A
decision was made to reinvestigate the care and treatment provided to Ms Smalley and
an investigating officer from the MHLD Quality Governance Team was allocated.
In May 2022, the new investigation report (COM52706), was shared electronically with
Mr Smalley. This report had a date of 04 April 2022. The report was shared with Mr
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
Smalley so that he could review it before a planned meeting on 23 May 2022 with the
investigating officer and a member of the MHLD Senior Leadership Team (SLT).
After the meeting with the investigating officer and a member of the SLT, Mr Smalley
returned the investigation report (COM52706) to the Health Board with additional
questions and requests for clarifications highlighted in bold red. The investigating officer
agreed to address the additional questions and clarifications within the report which would
be updated and re-sent to both Mr Smalley and the Coroner’s Office.
The final report that answered the additional questions and clarifications submitted by Mr
Smalley was shared with the Coroner’s Office on 6 April 2023. This has an additional ID
number of ID346, which reflects the migration to the new “Once for Wales” Datix system
(which we use to log and manage incidents and complaints). This has a date of 13
January 2023 as the date the author concluded the report. This final report has additional
actions to the first report (INC258782) completed in 2021 and these additional actions
were completed between April 2023 and August 2023.
I share your concerns about the length of time between Ms Smalley’s death and the
completion of all actions identified in the investigation reports that were shared with you
and Mr Smalley. I would like to take this opportunity to reaffirm our commitment, to you
and the family and friends of deceased patients, to implement systems that enable us to
identify improvements in a much timelier manner.
The Health Board is now fully reviewing the incident process to identify where it can be
improved and strengthened. A workshop was held on the 23rd October 2023 to identify
current issues and to begin the work of revising our process. The concerns you have
identified in this notice, and in other notices, are being directly fed into this work. We are
working in co-designing the process with staff and patient representatives, such as the
independent Llais organisation, to implement a completely new and improved approach
where the focus is on learning and improvement. During November 2023 we are meeting
with the IHCs and Divisions for their collaboration and engagement in developing the
process. The draft process will be submitted for review at the Health Board Patient Safety
Group in January 2024 then ratified in Quality and Safety Executive Committee for a
planned launch in April 2024 (which reflects the need to co-design our process,
implement new systems and train staff
I hope this gives you assurance that we are
listening to your concerns and plan to make significant improvements to our processes
and ways of working.
Within the MHLD Division specifically, there have been a number of changes to
strengthen the existing governance processes that underpin the management of action
plans for improvement.
The progress of reviews of incidents and complaints, and action plans arising from
completed reviews, are monitored locally at the Putting Things Right (PTR) weekly
meeting which is chaired by the Head of Nursing. All incidents, concerns and action plans
are also monitored by the Quality Governance team, reporting weekly to Divisional PTR
which is chaired by the deputy director of nursing, and any delays or breaches in
timescales are highlighted. In June 2023, the Quality Governance team also began
monitoring the receipt of evidence for completed actions via this forum. The Divisional
PTR meeting reports to the Divisional SLT on a weekly basis and into the Divisional
Quality Delivery Group on a monthly basis escalating any delays in the progress of
reviews or actions. The expectation is that all complaints and incidents will be reviewed
in line with the timescales set out by The National Health Service (Concerns, Complaints
and Redress Arrangements) (Wales) Regulations 2011 and any delays are escalated
each week to the Divisional SLT.
In addition, the MHLD Division has implemented a Learning and Action Group, the
function of which is to support the embedding of learning identified from a variety of
sources, including incidents and complaints.
The MHLD Division has a close working relationship with the Healthcare Law Team who
coordinate inquest activity for the Health Board. The Divisional Heads of Nursing meet
each week with the Healthcare Law Team and the Head of Governance. This has further
strengthened the timely submission of reports and evidence of completed actions.
Within the notice, you also raised your continued concerns about the implementation of
digital patient records for MHLD. In previous correspondence with you, the Health Board
has reported significant delays with the development and implementation of a suitable
system at a national level. I understand that you have raised your concerns about the
delays with the Health Minister directly. We now know that following a decision made by
WG the national system will not be progressing in the way that was previously expected.
This has significantly altered MHLD divisional plans for digital transformation as these
were dependent upon the use of the WCCIS Care Director Version 5 product, with a pilot
having been due to start in September 2023, and the expectation that a wider adoption
across all applicable MHLD services would follow. Regional meetings are now taking
place across Wales to discuss the options that have been presented to them by WG as
alternative to WCCIS Care Direct Version 5. BCUHB has met with Local Authorities to
discuss implications across health and social care services in order to come to an
agreement on the preferred option for North Wales.
In addition I am pleased to report that a Strategic Outline Case for an Electronic Patient
Record system(s) is being developed on a Health Board wide level to address the issue
of fragmented care records; the deadline for the strategic outline case is the end of
January 2024. MHLD are taking a key role in shaping the outline case to ensure that the
Division’s needs are considered as part of the Health Board wide proposal.
Whilst MHLD are keen to support and progress the processes outlined above, we are
mindful of the scale of the task for agreeing a national solution and are therefore working
with BCUHBs Chief Information Officer to consider options which may bring MHLD a
more timely solution. This remains a major priority for the Division and is supported by
the Health Board.
I hope this letter sets out for you the actions we have taken to ensure the concerns you
raised are being addressed. In particular, I want to assure you we are listening to your
concerns around investigations and plan to undertake a significant piece of work as
outlined above to make long term, substantial changes.
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 Ms Smalley 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 (Executive Lead for Metal Health)
, Deputy Director of Quality
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