Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0423, written 31 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2023 |
|---|---|
| Reference | 2023-0423 |
| Deceased | Andrew Bowles |
| Coroner | Ana Samuel |
| Coroner area | Birmingham and Solihull |
| Category | Other related deaths |
| Organisation named | Sandwell and West Birmingham Hospitals NHS 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.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Sandwell and West Birmingham NHS Trust and Birmingham and Solihull Mental Health NHS Foundation Trust. CORONER I am Ana Samuel, Assistant Coroner for Birmingham and Solihull 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. INVESTIGATION and INQUEST On 1 June 2023 I commenced an investigation into the death of Andrew BOWLES. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Drowned in a canal, having recently attended hospital suffering with a deterioration in mental health. It is unknown how he entered the water nor his intent at the time. CIRCUMSTANCES OF THE DEATH On 15th May 2023 the deceased, who had an extensive mental health background including self-harm, was taken to Birmingham City Hospital, concerns having been raised after he had been seen running in and out of traffic. He was deemed medically fit and was referred for psychiatric assessment. Following assessment referrals were made to the home treatment team and the homeless pathway team, there being no undue concerns noted by psychiatric liaison. Discharge was documented at 23.30, with an expectation that the deceased would remain in A&E until the following morning. CCTV footage showed the deceased leaving the hospital grounds at 23.28. The deceased was found face down in the canal under the road bridge of Dudley Road at 6.34 on the 16th May 2023, it being unclear how and when he entered the water. Following a post mortem the medical cause of death was determined to be: 1a Drowning 1b 1c II 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. Mr Bowles had an extensive mental health history with incidents of self-harm and suicidal intent. 2. On 15th May 2023 Mr Bowles had told attending paramedics and the triage nurse at Birmingham City hospital that over the last 24 hours he had been hearing voices that were telling him to hurt himself and others. When he was seen, post triage, by the doctor (SHO) Having been deemed to have no physical health needs a referral was made to the psychiatric liaison team. 3. The mental health liaison nurse from Birmingham and Solihull mental health NHS foundation trust did not have a log in to be able to directly access City Hospital records, but rather relied on a colleague to access any notes and provide a verbal handover. Further, she stated in evidence that her assessment may have taken place prior to the A&E notes being put onto the system, as she was unaware that Mr Bowles had been experiencing command hallucinations and had thoughts of self-harm, the same being denied when she saw him less than an hour later. Her evidence was clear, that had she been privy to this information, it would have put a different angle on the assessment and would have led down the route of psychiatric review for potential admission. 4. I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment. I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment. The situation may well be the same at University Hospitals Birmingham, given that Birmingham and Solihull Mental Health NHS foundation Trust also run a mental health liaison service in the A&E department. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 December 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The next of kin. I have also sent it to the Medical Examiner, Birmingham and Solihull Integrated Care board, Public Health England, Department of Health, University Hospitals Birmingham NHS Foundation Trust 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 6 7 8 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. 31 October 2023 9 Signature: Ana Samuel Assistant Coroner for Birmingham and Solihull
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.
Legal Department
Uffculme Centre ,
52, Queensbridge Road
Birmingham
B13 8QY
Date: 21 December 2023
Mrs A Samuel,
Assistant Coroner,
Birmingham and Solihull Areas,
Steelhouse Lane,
BIRMINGHAM B4 6BJ
Dear Mrs Samuel,
RE: Andrew Bowles
Thank you for your Prevention of Future Deaths letter of the 31 October 2023 raising the
concerns you have around the sharing of information between the two trusts on the front line,
specifically in relation to the accessing of electronic patient records. We have worked together
to try and address your concerns and therefore felt that it would be beneficial to provide a joint
response in regard to the matters arising from your PFD.
We would like to begin by assuring you that the staff in Accident and Emergency do work
closely with the Psychiatric Liaison Team to ensure the safe care of patients. For some time
the permanent staff in the Psychiatric Liaison Team (PLT) based at City Hospital Accident and
Emergency Department (A&E) have been able to access the electronic records and also
contribute to the records of the Sandwell and West Birmingham NHS Trust. This has been
crucial in keeping not just the A&E and PLT staff up to date but also the Ward staff, if a patient
is admitted.
In the past any “bank staff” (temporary staff) who were on shift would ask a member of the
permanent team to access the records, so that they could review them prior to seeing a patient
and would also ask permanent staff to update the records, following their review. Following
the PFD, a joint meeting has taken place between the two trusts, and we have been able to
identify that a number of the bank staff are regularly working bank shifts within the PLT.
Therefore these staff will now be allocated access to hospital records. This will improve
matters considerably in this area.
There are a small number of staff who may be called in from agencies when there are no other
staff available. As these staff may be new to the team and/or to both trusts and only working
one shift, it is unlikely that an account is set up immediately for them with the Hospital. In
these exceptional circumstance, when the local induction takes place, they will be advised of
the processes in place for them to speak with other permanent team members to access the
City Hospital notes. They will review them prior to speaking with the patient and also update
the records with their assessment after. Now that BSMHFT bank staff also have access to the
Customer Relations: Mon–Fri, 8am–6pm │ Tel: 0800 953 0045 │ Email: bsmhft.customerrelations@nhs.net
│ Website: www.bsmhft.nhs.uk
notes, there will be more staff with access to the records available to support this. They will
also be able to update hospital staff with their reviews and fully support staff through joint
working. Any issues will be monitored through clinical governance at BSMHFT.
Please be assured, we did explore all possible options including providing a generic log on for
agency only staff who may be carrying out one shift. However from an information governance
perspective it would not be possible to ascertain who had inputted the information and
therefore there would be no traceability or accountability in place, if any problem arose. This
is contra to the lawful processing of confidential information. Therefore the only option
available was to strengthen the number of PLT staff who have access to the City Hospital
records to address any concerns going forward and ensure smooth working.
We would like to assure you that we are working very closely together to ensure that all
patients receive the right care at the right time. We appreciate that sharing of information is
crucial for this to take place and so are working to resolve this problem as a matter of urgency.
We hope this offers you full reassurance in respect of the issues you have raised.
Yours sincerely
Chief Executive
BSMHFT
Chief Executive
Sandwell and West Birmingham NHS Trust
Customer Relations: Mon–Fri, 8am–6pm │ Tel: 0800 953 0045 │ Email: bsmhft.customerrelations@nhs.net
│ Website: www.bsmhft.nhs.uk
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