Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0371, written 4 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Oct 2023 |
|---|---|
| Reference | 2023-0371 |
| Deceased | Ronald Harris |
| Coroner | Hugh Bricknell |
| Coroner area | Herefordshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
4 October 2023 H G Mark Bricknell Senior Coroner for County of Herefordshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Managing Partner, Hereford Medical Group 1 CORONER I am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire 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. http ://www.legislation.gov.uk/ukpga/2009/25/schedule/S/paragraph/7 http://www.legislation .gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 14 June 2023 I commenced an investigation into the death of Ronald Leslie HARRIS. The investigation concluded at the end of the Inquest on 27 September 2023. The conclusion of the Inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH a) On the 24th April 2023 the Patients' wife contacted the practice indicating her husband had mental health difficulties. The symptoms were said to be getting worse . b) The Patients' family requested further help from the surgery on the 27th April 2023. The family were very concerned , indicating behaviour out of character and requesting GP input. Were told to expect a call the following week. c) A routine appointment was offered which the Inquest was advised would be 4-6 weeks. No call was made. d) The Patient received correspondence (copy to GP) in connection with cancerous lesions dated 23rd May 2023. No apparent reference on documents supplied to Inquest showing mental health position and no connection made between mental health position and correspondence. e) The Patient committed suicide on the 5th June 2023 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) Triage documentation was not fully completed. (2) The patient was not telephoned as requested and as advised they would be. (3) The Inquest was advised the triage Doctor was not aware of the waiting time for a routine appointment (4-6 weeks) nor did he consider the transcript of the telephone call. (4) The Deceased died on the 5th June 2023. The Inquest was told that a significant event meeting on the 9th August 2023 had indicated a review of protocol criteria for triaging patients with mental health problems was being undertaken. The Inquest was held on the 27th September 2023 no revised protocol was advised. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, the power to take such action . have 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 November 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 Chief Coroner and Local Mental Health who may find it useful or of interest. 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 4 October 2023 sign atu re-+-_ __e__+-'"--------'~~,£_+-¼-"---=- H G Mark
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.
H G Mark Bricknell HM Senior Coroner: Herefordshire Dear H G Mark Bricknell, Re: Regulation 28 Report to Prevent Future Deaths We have taken the time to closely review the Regulation 28 Report and consider our response. We will now endeavour to respond to the points raised in the report. 1. Triage documentation was not fully completed Hereford Medical Group uses an online system to record patient communication and online triage form submissions. These can either be completed by patients and submitted electronically or for patients who are unable to access the online form, these can be completed by a Receptionist on behalf of the patient. In this instance the information was recorded by a receptionist but unfortunately, the form did not save correctly; the Receptionist subsequently recognised this and went back retrospectively to re-complete the form by memory. For information, 15% of online triage forms are completed by Receptionists on behalf of patients. Where further information is required from a patient then there is a system in place to support this. We also noted learning from this event and have since implemented a new process whereby if an online form was not available for a clinician, they are able to arrange to listen to the phone call. 2. The patient was not telephoned as requested and as advised they would be We have reviewed the transcript of the telephone call dated 27th April 2023. The receptionist advised the daughter-in-law that the surgery would be in touch within 5 working days. The reason for this timescale is to allow for the form to be triaged by the GP to determine whether an urgent, soon or routine appointment is most appropriate. It would appear from your report that the patient’s daughter-in-law interpreted this as a Doctor would be calling the patient within 5 days. A transcript of the relevant part of the call is given below for your reference. HMR reception Caller HMG reception Caller HMG reception Caller HMG reception Ok that’s lovely Should I expect him to expect a call today or will it be over the next couple of days? So this form that we have completed will go across to the doctor and we will be in touch within 5 working days with what the doctor would like to do. Ok no problem that’s fine no worries, I’ll just tell him to expect a call. That’s fine thank you very much. Yes, It should be next week, because we have the Bank Holiday obviously so that might slow things up slightly alright. That’s alright, no worries. Thank you for helping me. Thank you. Take care Bye When patients complete a triage form they are asked to indicate their preference for contact including phone or SMS. We have updated the protocols that the team follows and the reception team, who usually undertake the actions indicated following triage, now telephone the patient in the first instance to advise on the GPs triage decision. 3. The inquest was advised the triage Doctor was not aware of the waiting time for a routine appointment (4-6 weeks) nor did he consider the transcript of the telephone call We have taken significant measures to reduce the wait time for routine appointments by increasing the number of available routine appointments. The wait for a routine appointment is under continuous review and our current wait is around approximately 4 weeks. In future, this information will be communicated to all staff on a weekly basis using the staff newsletter. All triaging GPs are aware of how to find appropriate triage appointments. Calls are not routinely transcribed at the practice; when the Significant Event Analysis (SEA) meeting took place we ensured that a copy of the transcription was available to confirm what the receptionist advised was reflected in the call. We believe that nothing was discussed in the telephone call that would have influenced the triaging outcome. 4. The deceased died on the 5th June 2023. The inquest was told that a significant event meeting on 9th August 2023 had indicated a review of protocol criteria for triaging patients with mental health problems was being undertaken. The inquest was held on the 27th September 2023 and no revised protocol was advised. We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for Registered Address: Station Medical Centre, Station Approach, Hereford, HR1 1BB making sure that triaging GPs are aware of the next available routine and soon appointment slots. However, as part of regular and ongoing training for GPs, one of the lunchtime sessions over the next month will be on Mental Health. In addition, the next protected education time in January will be focused on triaging, including clinical considerations and the triage process and protocols. To conclude, the practice has reviewed the Prevention of Future Deaths report and I trust that the answers to the specific concerns that you raise in the report have been addressed. If there are any further questions that arise as a result of this response then I would be pleased to address them. Yours sincerely, Managing Partner Registered Address: Station Medical Centre, Station Approach, Hereford, HR1 1BB
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