Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2023-0365, written 1 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Nov 2022 |
|---|---|
| Reference | 2023-0365 |
| Deceased | Rowan Thompson |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. EE Chief Executive Greater Manchester Mental Health Trust 2. EE Chief Executive Officer of NHS England CORONER | am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 7" October 2020, | commenced an investigation into the death of Rowan Louis Thompson. Rowan died on the 3 October 2020. The investigation concluded on the 31% October 2022. The medical cause of death was confirmed as 1a) Cardiac Arrythmia 1b) Severe Hypokalaemia of unknown cause. A jury recorded a narrative conclusion which noted that that Rowans death was contributed to by neglect, in that there was a failure to communicate the finding of blood tests analysed at Salford hospital on the 2 October which showed a life-threatening severe | Menevem CIRCUMSTANCES OF DEATH Rowan was a detained patient in the Gardner Unit at Prestwich hospital. This is one of four national forensic medium secure units for adolescents (aged 11-18). Its patients are often high risk (either to themselves or others) and have been accused of some of the most serious criminal offences. On the 3% October 2020 Rowan was found in his room and it was thought he was having a seizure. CPR was commenced and paramedics called. Rowan died shortly after his arrival at North Manchester General Hospital. During the course of the investigation it became apparent blood test results had been available at Salford Royal hospital 24 hours earlier which indicated Rowan was suffering from severe hypokalaemia a medical emergency. There had been a failure to communicate those results in part due to errors at Salford and also at GMMH. During the course of the evidence the court heard of the failure by at least four staff members to undertake observations on Rowan on the morning of the 3 October 2020. In addition witnesses confirmed that records were falsified to show the observations had been undertaken. During this shift no deputy ward manager or ward manager were on duty. The court heard there is no commissioning for deputy or ward managers to work at weekends. Both nurses working that day were still in their preceptorship being newly qualified. At least one, likely both had never been in a situation where they were faced with a medical emergency and having to consider CPR. The Court heard evidence in respect of the calling and arrival of the ambulance. It was clear that there was a delay in the paramedics attending Rowan due to it being unclear on the Prestwich site where the Gardner unit was, a lack of persons looking out for the paramedics and then them not being able to swiftly enter the locked unit. | Following Rowans death a number of investigations were undertaken. There was no sufficient | consideration of the emergency response following Rowan being located in his room. Finally the court heard evidence as to the audit of the observation sheets which were (and continue to be) undertaken by managers. An investigation following Rowan’s death highlighted a further 6 staff who in the three week period prior to the 3 October 2020 failed to conduct observation checks. Despite this there is no ongoing audit of CCTV and the current audit of the observation logs will not highlight the falsifying of checks and documentation. 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:- 1. System by which observations and documentation are audited lacks rigour and is ineffective. 2. Atthe time of the CCTV review and investigation following Rowan’s death there was a missed opportunity for management to understand the gravity and nature of the situation. There was -no higher level investigation, so for example: a) Whether the staff who failed to complete observations/falsify records did so when working a particular shift ie night shift b) Whether the staff who failed to complete observations/falsify records did so when working weekends rather than during the week c) Whether there was any correlation between missed observations / falsifying of records and shifts when there was no deputy or ward manager on duty. 3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3° October 2020 was a concern. There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 27" December 2022. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- | 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 from. 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. A2 9 laa LT Nene, 2ADKAQ__ Signed:
2 responses 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.
21st December 2022
PRIVATE AND CONFIDENTIAL
Ms Joanne Kearsley
HM Senior Coroner
Manchester North Coroner’s Office
Floors 2 and 3 Newgate House
Rochdale
OL16 1AT
Dear Ms Kearsley
Trust Management Offices
First Floor, The Curve
Bury New Road
Prestwich
Manchester
M25 3BL
Re: Rowan Thompson (deceased) Regulation 28 Preventing Future Deaths Response
On behalf of Greater Manchester Mental Health NHS Trust (GMMH) I would like to offer
Rowan’s family our sincere condolences at this difficult time.
Ms Kearsley, thank you for highlighting your concerns during Rowan’s Inquest which
concluded on 31st October 2022.
On behalf of the Trust can I apologise that you have had to bring these matters of concern to
the Trust’s attention.
Please see the Trust’s response in relation to the concerns you have raised and the actions
taken by the Trust:
1. System by which observations and documentation are audited lacks rigour and is
ineffective.
And
2. At the time of the CCTV review and investigation following Rowan’s death there was
a missed opportunity for management to understand the gravity and nature of the
situation. There was no higher level, so example:
A) Whether the staff who failed to complete observations/falsify records did so
when working a particular shift ie night shift
B) Whether the staff who failed to complete observations/falsify records did so
when working weekends rather than during the week
C) Whether there was any correlation between missed observations / falsifying
of records and shifts when there was no deputy or ward manager on duty.
During the inquest the Associate Director of Quality gave evidence in relation to the daily
audits of observation records in our Child and Adolescent Mental Health Services (CAMHS).
Concerns were raised that these audits lacked vigour and were ineffective due to the themes
and times, days not being considered in the longer term, rather they are completed daily.
The managers of the service, supported by the Patient Safety Team will carry out a thematic
review of audits to identify any specific themes and resulting actions, this will be completed by
31st January 2023.
A8
The Trust acknowledge that the review carried out at this time did not provide a comprehensive
overview of observations that considered the practice of staff undertaking these outside the
timeframe reviewed. This was an HR investigation that appropriately met the terms of
reference set out for this review. The thematic review will address this.
The Trust is reviewing the use of therapeutic observations and engagement across the whole
Trust, being led by the Head of Nursing Practice. The purpose of the review is to identify best
practice standards and guidance on the management and practice of therapeutic observations
& engagement, legal framework and requirements for staff training and competency
assessment.
The task and finish group has been established, membership agreed, and terms of reference
developed.
A workshop was held with staff and patients on December 16th 2022 where priorities have
been agreed for the review of observations including:
• Review of Trust policy and practice by January 2023
• Review of staff training needs and development programme to support by February
•
2023
Identify a Division to carry out a test of change that will test out the priorities before
being implemented across the Trust
3. Given the specialist nature of the Gardner, the fact that this is a high risk
environment and somewhere where the situation can change in an instant given the
nature of the patients the experience of the staff in charge on the 3rd October 2020
was a concern. There was no rationale other than the commissioning why a deputy
or ward manager was not working at a weekend (when there are less activities to
occupy the patients). The evidence heard suggested to the court that a more
experienced nurse was always required on this unit.
Staffing requirements for the Gardener Unit are determined both by the number of ward based
nursing staff required to undertake planned tasks and duties during each shift (clinical care,
administration of medication, liaison with other professionals and security/environmental
requirements for example) and by the individual clinical and risk needs of the young people
resident on the ward at that time. Staffing numbers and skill mix are therefore dynamic and
can fluctuate on a shift-by-shift basis requiring close oversight of staffing to ensure that the
needs of the young people are met safely, and that staff are supported to provide effective
care.
Staffing at the Gardener Unit – as is the case for all other wards within CAMHS – is continually
monitored by local managers with review and approval processes in place at the time each
staff rota is produced and proactively, and on a rolling basis, to ensure that each individual
shift is fully staffed and takes into account any changes that may have occurred at ward level
since the staff rotas were first prepared e.g. a change in observations. Briefing meetings occur
in advance of every weekend to review staffing requirements for the full weekend and provide
the opportunity for local managers to make any required changes. This meeting had taken
place in advance of the weekend of the 3rd and 4th of October 2020 and no concerns about
the experience and skill mix of the staff had been identified; had there been such concerns,
corrective action would have been taken by local managers and the issue escalated to more
senior CAMHS managers.
A9
It is sometimes the case that the clinical needs of a ward can quickly change e.g. following an
incident or an increase in a young persons risk and out of hours there are clear systems in
place to enable ward based staff to request additional staffing to meet increased need; the
Nurse in Charge of a shift is able to utilise the Duty Manager to request additional short term
support e.g. immediately after an incident or to request an increase in staffing across a number
of shifts for an identified reason. In turn, the Duty Manager has access to on-call systems to
escalate and discuss any staffing concerns although it is important to note that the Duty
Manager is supported to make local decisions about staffing and additional permissions to
increase numbers are not required from the on-call structure.
The Gardener Unit has one Ward Manager and three Deputy Ward Managers in its
establishment; while Ward Managers do not typically work weekends, Deputy Ward Managers
do work shifts across the full week (including nights) but it is not possible to have a Deputy
Ward Manager working every shift at the Gardener Unit (and other wards). Weekends are
often viewed by the young people as an opportunity for more relaxed and individual time
(different to attending planned College lessons or sessions with an MDT member during the
week for example) but other activities and sessions do still take place supported by the nursing
team and these also include leave, planned visits and social type activities on the ward.
Ms Kearsley, on behalf of the Trust can I thank you for bringing these matters of concern to
the Trust’s attention. I hope this response demonstrates to you and Rowan’s family that
GMMH have taken the concerns you have raised seriously. If you have any further questions
in relation to the Trust’s response, please do let me know.
Yours sincerely
Medical Director
A10
Ms Joanne Kearsley
Senior Coroner
Manchester City Coroner's Office and Court
Exchange Floor
The Royal Exchange Building
Cross Street
Manchester
M2 7EF
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
10 March 2023
Dear Ms Kearsley
Re: Regulation 28 Report to Prevent Future Deaths – Rowan Louis Thompson
who died on 03 October 2020
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18
November 2022 concerning the death of Rowan Louis Thompson on 03 October 2020.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Rowan’s family and loved ones. NHS England are
keen to assure Rowan’s family and the coroner that the concerns raised about
Rowan’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise to
the family for the delay, as I appreciate this will have been an incredibly difficult time
for them.
Your Report concludes that Rowan’s death at the Gardner Unit at Prestwich Hospital
was contributed to by neglect; in that there was a failure to communicate the finding
of blood tests analysed at Salford Hospital on
October which showed a life-
threatening severe hypokalaemia. In your Report you listed three main concerns:
2nd
1. the system by which observations and documentation were audited
within the Gardner Unit;
2. missed opportunities during their initial investigation into failures to
complete observations as well as allegations staff were falsifying
records; and
3. the lack of a deputy or ward manager working at the weekend.
We understand you have also addressed this Report to Greater Manchester Mental
Health NHS Foundation Trust. They will address specifics as to the changes being
implemented on the ground.
1
A5
We would also like to share with you the wider strategic interventions that NHS
England has commenced. Greater Manchester Mental Health NHS Foundation Trust
is already receiving support to make improvements to the quality of their care as
part of the NHS England Recovery Support Programme.
We acknowledge the importance of, and rigour required when undertaking, recording,
documenting, and auditing observations and this forms a significant area of work as
part of an Improvement Plan that has been put in place by Greater Manchester Mental
Health NHS Foundation Trust and which will be monitored by the System Improvement
Board. As part of this improvement work, the Trust has appointed an Improvement
Director to support this work as well as an Interim Chair of the Trust.
The Improvement Plan includes a workforce establishment review for nursing, based
on the national Mental Health Optimal Staffing Tool (MHOST). The tool embraces all
the principles that should be considered when evaluating/implementing decision
support tools described in ‘Safe, sustainable and productive staffing: An improvement
resource for mental health (Safer_staffing_mental_health.pdf (england.nhs.uk) (NHSI,
2018). This work is supported by a safer staffing lead, baseline assessments of staffing
assessment will be
levels have been commenced and it is anticipated the
completed within six months and the results will form part of the enhanced recruitment
plan. The aim of the assessment is to ensure the right staff with the right skills are
available at the right place and time, specifically in relation mental health this relates
to reviewing the models of care, the resources and clinical risk mitigation to allow the
safe and effective patient assessment and treatment. In addition, daily reviewing and
reporting of the current staffing levels are occurring.
1st
On a national level, NHSE are prioritising making improvements to mental health
services, which are being implemented under the NHS Mental Health Implementation
Plan 2019/20 – 2023/24. The plan looks to increase spending and, crucially, staffing
levels, to include for secure mental health services, and will help ensure that patients
receive high quality, safe and therapeutic care.
In addition, NHS England’s (NHSE) have nationally commissioned an Independent
Review which is being managed and led by the Northwest Region. An external
Independent Chair has been appointed who is currently in the process of developing
the Terms of Reference for the review. As part of the review process the Independent
Chair will be making contact with Rowan’s family, to understand their experiences of
the care Rowan received.
The review will cover patient services at the Edenfield centre along with wider service
provision across GMMH. The review will particularly consider the patient failings and
clinical escalation concerns raised/identified by the Panorama programme and other
intelligence such as Care Quality Commission reports, and indeed Regulation 28
reports. It will identify whether these are systemic issues throughout the service or
isolated clinical incidents and to make recommendations as to what the Trust must
take to improve patient safety in the service. It is important to note, the review will also
look at the Trust’s other medium and low secure services and will include reviews of
ward to board escalation and oversight of patient safety and staff culture. We expect
the review to have concluded by the end of September 2023.
1
A6
It should be noted that the Independent Review will not be an investigation of
individualised care received by Rowan, but a broader review of services and culture
across the organisation.
NHS England has committed itself to transparency and will publish the findings of the
external Independent Review in the public domain on the website of NHS England, in
order that any learning identified can be shared as it is generally accepted that there
is a public benefit in the learning identified in such reviews.
I would also like to provide further assurances on national NHS England 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. The Working Group will review the findings
of the Independent Review in due course.
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. We will of
course publish the Independent Review once it has been completed and welcome
your and Rowan’s family’s involvement in its development, to ensure that the Review
is as effective in improving mental health care services not only in Manchester, but
nationally too.
Yours sincerely,
National Medical Director
NHS England
2
A7
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.