Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0366, written 16 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jun 2023 |
|---|---|
| Reference | 2023-0366 |
| Deceased | Vaughan Whalley |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | Suicide (from 2015) |
| Organisation named | Midlands Partnership University NHS Foundation Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive of Midlands Partnership NHS Foundation Trust 1 CORONER I am Catherine McKenna, Area Coroner for the Coroner area of Manchester North 2 CORONER'S LEGAL POWERS I 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 3 INVESTIGATION and INQUEST On 23 February 2023 an investigation into the death of Vaughan Lee WHALLEY (the Deceased) was commenced. The investigation concluded at the end of the inquest on 13 June 2023. I recorded a conclusion of Suicide 4 CIRCUMSTANCES OF DEATH At 22:38 hours on 19 February 2023, . He was found unresponsive the following morning and taken to the Royal Oldham Hospital where he underwent surgery to stem the extensive bleeding. Despite best supportive care, he died at the Royal Oldham Hospital on 21 February 2023. The Deceased had been released on bail from Worcester Police Station at 00:33 hours on 19 February 2023 after being detained for 24 hours. In the hours before his arrest, he had been identified by West Mercia Police as a high risk missing person because he had made threats to end his life. On arrival at the police station, the Custody Sergeant took steps to address the Deceased's risk of suicide by removing his belt, providing him with a rip proof blanket and making a referral to the Liaison and Diversion Service. The referral form included the fact that the Deceased had made threats to end his life. The Liaison and Diversion Practitioner (the Practitioner) attended the Deceased's cell at 10:03 hours on 18 February. A conversation took place through the observation hatch in the cell door which consisted of enquiring whether the Deceased wanted any help with unmet needs or vulnerabilities. During the conversation, the Deceased told the Practitioner that his thought of suicide had been a reaction to the allegations for which he was arrested and that these had now passed. The Court found that this conversation did not equate to a full assessment of the Deceased's risk of suicide or self-harm. Furthermore, the Practitioner indicated that it was not his role to assess whether the Deceased presented a risk of suicide or self-harm on release from custody. The Practitioner made no entry of his contact with the Deceased in the Detention Log. The Court found that there was a lack of clarity in the handover information given to the police as to what. if any, assessment had taken place. 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 :- (1) No assessment of the risk of suicide or self-harm upon release took place during the Deceased's time in detention (2) There was a lack of clear communication to the Police as to what, if any assessment had taken place. (3) The conversation between the Practitioner and the Deceased took place through an observation hatch in circumstances where no risk was posed to the Practitioner from being in the same room as the Deceased. This was not best practice. (4) The terminology used by the Practitioner was misleading in that it suggested that there was no role for the liaison and Diversion service because no unmet needs or vulnerabilities had been identified. The evidence was that the Deceased had declined consent for an assessment of unmet needs and vulnerabilities and therefore the notes should have made clear that an assessment of unmet needs and vulnerabilities had not taken place. (5) The 'review' undertaken by a Health & Justice Operational Manager of the West Mercia Health & Justice Service consisted of duplication of the Practitioners statement with no comment, observations or identification of areas of learning. 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 August 2023. I, the Area 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 namely:- • • Chief Constable of West Mercia Police • Care Quality Commission (family of the Deceased) 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 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. Date: 1r1'1Are '23 Signed: Cd \ I
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.
Chief Executive
Trust Headquarters
St George’s Hospital
Corporation Street
Stafford
ST16 3SR
Ms C McKenna
His Majesty’s Area Coroner for Manchester North
3rd August 2023
Dear Ms McKenna
RE: Vaughan Lee Whalley (deceased)
Report to Prevent Future Deaths
Thank you for your letter dated 16th June 2023, reporting a matter to us, in accordance with
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
May I take this opportunity to reassure you that following the inquest in to Mr Whalley’s
death, we undertook a thorough investigation into the care delivered by the Midlands
Partnership University NHS Foundation Trust.
MATTERS OF CONCERN:
The five areas of concern were:
1. No assessment of the risk of suicide or self-harm upon release took place during Mr
Whalley’s time in detention.
2. There was a lack of clear communication to the police as to what, if any, assessment
had taken place.
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3. The conversation between the Practitioner and Mr Whalley took place through an
observation hatch in circumstances where no risk was posed to the Practitioner
from being in the same room as Mr Whalley. This was not best practice.
4. The terminology used by the Practitioner was misleading in that it suggested there
was no role for the Liaison and Diversion Service because no unmet needs or
vulnerabilities had been identified. The evidence was that the deceased had
declined consent for an assessment of unmet needs and vulnerabilities and
therefore the notes should have made clear that an assessment of unmet needs and
vulnerabilities had not taken place.
5. The “review” undertaken by a Health and Justice Operational Manager of the West
Mercia Health and Justice Service consisted of a duplication of the Practitioner’s
statement with no comment, observations or identification of areas of learning.
Following discussions within the Health and Justice Services in the Specialist Services Care
Group and with corporate services, I am now in a position to respond to the specific
concerns raised during the course of the inquest.
1.
No assessment of the risk of suicide or self-harm upon release took place
during Mr Whalley’s time in detention.
As a result of the concerns raised we have undertaken a review of the risk
assessment processes across our Health and Justice Services. Some
inconsistencies in the standards were identified which we have addressed by the
development of a Standard Operating Procedure for risk assessment to be
applied across Health and Justice Services. The SOP incorporates standards for
conducting and sharing risk assessments for people in Police custody. Included
in the SOP is a requirement for risk related information to be recorded in the
appropriate place in Police IT systems.
The SOP remains in draft until it has been ratified by MPFT Policies and
Procedures Committee on the 09/08/23. Staff have been advised of the revised
standards and the standards have been incorporated into clinical practice.
The revised standards will be supported and embedded by delivery of Suicide
Mitigation Training to all clinical staff working in Health and Justice Services.
Level 1 training is an e-learning programme for all clinical staff. Level 2 training
is a taught session, also for all clinical staff. Level 3 training is a taught session
for all registered practitioners.
All clinical staff are required to complete the e-learning programme before
attending Level 2 and/or Level 3 training as appropriate.
Seven Level 2 and Level 3 training sessions are planned for delivery during
September, October, November and December, with the final training session
planned for the 15th December, with the aim that all staff working in Health and
Justice Services are trained by the end of 2023.
2
We have written to the Chief Constable of West Mercia with an offer to explore
the possibility of extending suicide mitigation training to Police staff working in
custody if it is felt this would be appropriate.
2.
There was a lack of clear communication to the police as to what, if any,
assessment had taken place.
The review of Mr Whalley’s care indicated that no entry was made on the
Police IT system regarding the assessment carried out by the L&D Practitioner.
The entry in Mr Whalley’s Electronic Patient Record (EPR) indicates that verbal
feedback was given to ‘relevant parties in Police custody’. The content of the
verbal feedback and the name of the person or persons to whom the feedback
was reportedly given are not noted.
As noted above a Standard Operating Procedure for conducting and sharing
risk assessments for people in contact with Health and Justice Services,
including whilst in Police custody, has been developed and circulated to all
staff working in Health and Justice Services. In addition to the requirement for
staff to record a summary of risk related information in Police IT systems is the
requirement for staff to record the content of any additional, verbal feedback
relating to risk and the names of the people to whom the feedback was given
in the EPR.
If the service user declines to engage in a risk assessment staff will record this
in the EPR, being clear that this does not mean that there are no risks of future
self-harm or suicide.
3.
The conversation between the Practitioner and Mr Whalley took place
through an observation hatch in circumstances where no risk was posed to
the Practitioner from being in the same room as Mr Whalley. This was not
best practice.
The review of Mr Whalley’s care confirmed that the conversation with the
Practitioner took place through an observation hatch.
Following a review, the Health and Justice Services SOP ‘Working in Police
Custody’ has been revised to include guidance for staff on the circumstances
under which it is appropriate to review somebody through an observation
hatch and the process for recording where and with whom an assessment took
place and the rationale for conducting an assessment through an observation
hatch if this was necessary. The SOP will be ratified at the MPFT Policy and
Procedures Committee on the 09/08/23. I will forward a copy of the SOP as
soon as it has been ratified.
4.
The terminology used by the Practitioner was misleading in that it suggested
there was no role for the Liaison and Diversion Service because no unmet
needs or vulnerabilities had been identified. The evidence was that the
deceased had declined consent for an assessment of unmet needs and
3
vulnerabilities and therefore the notes should have made clear that an
assessment of unmet needs and vulnerabilities had not taken place.
As noted above, the Health and Justice Service SOP ‘Working in Police Custody’
has been reviewed. The SOP now contains guidance for staff, that in the event
that a service user declines consent for an assessment of their needs and
vulnerabilities, it is clearly recorded in the EPR and the relevant Police IT
system that no assessment has taken place.
5.
The “review” undertaken by a Health and Justice Operational Manager of the
West Mercia Health and Justice Service consisted of a duplication of the
Practitioner’s statement with no comment, observations or identification of
areas of learning.
As a result of the concerns raised regarding the quality of the review undertaken
by the Operational Manager we have made a number of changes.
We have agreed a new process, outlined in the Health & Justice SOP Review of
cases referred by the Coroner's Court, whereby Service and Team Leaders no
longer review the care delivered within their own service or team. The new
process outlines the responsibilities of staff involved in producing and reviewing
statements and we have reviewed the template for reports to ensure that future
reports do not contain a duplication of the statements of other staff members
and do contain appropriate comments, observations and areas of learning.
Additional training in Court Report writing skills, focussing specifically on reports
for the Coroner’s Court, has been arranged for Team Leaders and Service
Managers who may be called to provide evidence about the quality of care
delivered to people who use our services.
The training will be delivered on the 19th of September 2023.
MPFT will be transitioning to the new Patient Safety Incident Response
Framework (PSIRF) in September 2023. PSIRF will provide improved support for
those involved in undertaking investigations improving the safety of the care
we deliver to people; the quality of reports produced and supporting shared
learning to maximise improvements in healthcare.
To support the embedding of this process within Health and Justice Services
the Head of Health and Justice Services is currently undertaking PSIRF training
during July 2023. In addition, the Clinical Director for Health and Justice
Services is a member of the PSIRF Project Delivery Group responsible for
ensuring that the processes are embedded across MPFT’s clinical services.
We have also written to the Chief Constable of West Mercia to propose that
future investigations of suspected self-harm deaths relating to individuals who
have been in custody are carried out jointly between Midlands Partnership
University NHS Foundation Trust (MPFT) and West Mercia Police to support
shared learning and help prevent future deaths.
4
Progress against the actions outlined above will be monitored through our Health and
Justice Services Integrated Governance Meeting and in Contract Review Meetings with NHS
England Commissioners. In addition, compliance with the record keeping standards
outlined in the SOP for risk assessment in Health and Justice Services will monitored through
the regular audit of clinical notes.
I hope this response helps to address your concerns. However, if you require any further
information please do not hesitate to contact me.
Yours sincerely
Chief Executive
Midlands Partnership University NHS Foundation Trust
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