Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0333, written 14 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 | 14 Sep 2023 |
|---|---|
| Reference | 2023-0333 |
| Deceased | Richard Griffiths |
| Coroner | Kate Robertson |
| 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.
Kate Robertson Assistant Coroner for North Wales (East and Central) 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, Assistant 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 30 March 2023 an investigation was commenced into the death of Richard Geraint Griffiths (DOB 12/1/70) who died on 26 March 2023. The investigation concluded at the end of the inquest on 14 September 2023. The conclusion of the inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- Richard Griffiths moved home to the Conwy area from South Gwynedd in October 2022 to live with his mother. He was under the care of the South Gwynedd Community Mental Health Team. For reasons unknown the transfer of care did not occur. Sadly, on 26 March 2023 he was found suspended was cut down and the emergency services were also called. He was pronounced deceased at the location. . Once he was found he 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 – Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN a. The Investigation undertaken by the Health Board was deficient in that it did not contain pertinent points relating to how the transfer of care did not occur. I have previously issued a number of Prevention of Future Death Reports relating to quality and timeliness of investigation. b. The Health Board’s Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur. The amended policy has still not been finalised and there remains a concern that deaths will continue to occur if the process is not finalised and shared widely within the Health Board to staff. c. Patient notes for mental health are still not electronic; they are paper based. I have issued several Prevention of Future Death Reports specifically relating to this. There has been considerable delay in actioning this and yet there is still not anticipated timescale for this to occur. As such, deaths will continue to occur or may occur into the future with the risk that notes are paper based only. The risk relates to only one department or individual having access to them at once when there is wider support for the patient. 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 9 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, to the Chief Coroner and to , Health Minister. 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 14 September 2023 Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Signature Assistant 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: 3 November 2023 Kate Robertson Assistant Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Dear Ms Robertson, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Richard Geraint Griffiths I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated the 14th September 2023, issued by yourself to Betsi Cadwaladr University Health Board following the inquest of Mr Griffiths. I would like to begin with offering my deepest condolences to the family and friends of Mr Griffiths. In the notice, you highlighted your concerns that the Health Boards investigation into the care and treatment provided to Mr Griffiths was not of the expected standard. In response to the notice, I asked our Mental Health and Learning Disabilities Division (MH&LD) to consider your concerns and provide details of their plans to ensure the provision of robust investigation reports and action plans for improvement. , the Director of MH&LD Division, reported to you on the 14th September 2023 that an addendum investigation would be undertaken to expand on the pertinent points relating to how the transfer of care of Mr Griffiths did not happen. The investigation is underway, and the investigating officer (IO) has undertaken interviews with staff directly and indirectly involved in Mr Griffiths’ care and treatment. The IO has considered the transfer process that was in place at the time Mr Griffiths was receiving care, the improvements that have been made since, and the review of the Transfer and Discharge of Care Protocol. The addendum report is currently progressing through the Health Board’s approval process and I will be happy to share this with you on its completion in the coming weeks. On the 15th September 2023, the Quality Governance team contacted the Heads of Operations and Heads of Nursing throughout MH&LD to share the concerns you raised about the quality of the investigation report. The Quality Governance team requested that in future, IOs meet with the staff involved in the delivery of care and treatment to explore in detail the decision-making and actions taken when delivering care and that the 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 outcome of reports are shared with the staff involved. The Quality Governance team now also check for this aspect during the quality assurance of reports. This will ensure more detailed investigations that get to heart of the contributory factors and the root causes of incidents. The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol is due at MH&LD Policy and Procedure Group in December 2023 after which it will progress through the Health Boards revised ratification process. I anticipate that the protocol will be ratified by the end of January 2024. Within the notice, you also raised your continued concerns about the implementation of digital patient records for MH&LD. 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 MH&LD 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 MH&LD 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. MH&LD 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 MH&LD 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 MH&LD 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. 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 Griffiths for their loss. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Deputy Director of Quality
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