Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0436, 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 | 2023-0436 |
| Deceased | Jack Farrington |
| Coroner | Robert Simpson |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Mental Health related deaths |
| Organisation named | Solent NHS Trust · Portsmouth Hospitals University NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 2 3 1 CORONER , CEO Portsmouth Hospitals University NHS Trust , CEO Solent NHS Trust , CE NHS England I am Robert SIMPSON, Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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 08 January 2020 I commenced an investigation into the death of Jack FARRINGTON aged 26. The investigation concluded at the end of the inquest on 27 July 2023. The conclusion of the inquest was that: On the 2nd January 2020 Jack Farrington died as a result of falling from a bridge. At the time, Jack was detained under section 2 of the Mental Health Act due to recent psychotic episodes. Evidence suggests that Jack's capacity to make rational decisions was severely compromised. When Jack was lucid he demonstrated a desire to be well and actively sought medical assistance for his condition. In the days prior to his death Jack had voluntarily attended hospital via ambulance. During Jack's time in hospital, he was able to abscond twice, and was sectioned under the Mental Health Act and transferred to a mental health facility. Following a suspected medical emergency Jack was transported back to hospital under escort. Significant failings in the assessment, recording, sharing of information, accountability and implementing appropriate measures to keep Jack safe contributed to his ability to abscond a third time, resulting in Jack's death. 4 CIRCUMSTANCES OF THE DEATH Regulation 28 – After Inquest Document Template Updated 30/07/2021 Jack Farrington had a long history of mental health difficulties. He moved to Hampshire in 2019 and his mental health started to deteriorate again later that year. He sought help from his GP and the community mental health services. On the 30th December he called an ambulance in a state of acute distress. He was transported to Queen Alexandra Hospital, Portsmouth (QAH) and assessed in the emergency department (ED). He was moved to the observation ward and seen by a consultant who requested further assessment to determine whether Jack needed to be detained under the Mental Health Act. Before this happened, Jack absconded from the observation ward via the fire door at approximately 9.00am. Jack was located by the police and returned to the ward where he was detained under s.5(2) of the Mental Health Act. He was subsequently detained under s.2 of the Mental Health Act. On the 31st December 2019 Jack absconded via the same route despite being under 1:1 supervision by a registered mental health nurse. Jack was located and returned to the ward by the police. In the early evening of the same day Jack was transferred to St James’ Hospital and admitted to the Hawthorn ward. On the 1st January 2020 Jack threw himself at a glass dividing wall. On the 2nd January 2020 Jack suffered a medical episode and was transferred by ambulance to the emergency department of QAH. He was accompanied by 1 escort from St James’ Hospital and remained within the ED awaiting medical assessment and treatment. At approximately 10.00am Jack ran from the ED and shortly after this fell from a road bridge sustaining fatal injuries. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) NHS England Jack moved from Shropshire to Hampshire in the year leading up to his death. He had been under the care of the Midlands Partnership NHS Foundation Trust for many years in relation to his mental health difficulties and they held significant Regulation 28 – After Inquest Document Template Updated 30/07/2021 records. He was assessed as stable in 2019 when he moved to Hampshire and was discharged from their service. When Jack became unwell again neither the community mental health team nor the in-patient mental health team of Solent NHS Trust were able to access Jack's records from the Midlands and a copy had to be requested. For a number of reasons this was not available prior to Jack's death and this may have impacted the decision making ability of the staff caring for Jack. I heard evidence that there is no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas and the Care and Health Information Exchange (CHIE) operating in the local area contains limited information. I also received evidence that the new NHS England National Record Locator system only acts as a flag to show who holds records rather than allowing access to clinicians. This fragmentation of patient records means that medical and mental health practitioners do not have quick access to relevant information about their patients. In Jack’s case he was detained under the Mental Health Act on New Years Eve and at the start of a bank holiday weekend. As such the staff of the mental health unit did not have any way to obtain his records during the out of hours period. Solent NHS Trust I am pleased to hear that since Jack’s death and the subsequent inquest Solent NHS Trust have updated their training and guidance to staff members who are escorting detained patients. Additionally they are introducing an alert system within SystmOne for patients at increased risk of absconding and/or self-harm. There remain 2 areas of concern: 1. Handovers I heard evidence that the staff within the secure mental health unit rely very heavily on information given at handovers at the start of a shift and they do not have time to review the patient records in detail. At the time of Jack’s death records of these handovers were not stored in the same way as other patient records and, in Jack’s case, were missing entirely. This significantly hampered the investigation and inquest. I am pleased to hear that Solent NHS Trust have now changed their document storage policy in this regard and these records will now be added to and stored on SystmOne. However the handover records are not currently completed within SystmOne. This gives rise to the continuing risk of this information not being correctly recorded or correctly stored. I understand that this requires a change to SystmOne which is not yet complete. Regulation 28 – After Inquest Document Template Updated 30/07/2021 2. Paper & electronic records Solent NHS Trust still relies on paper forms for some observations and record keeping within the mental health unit. In Jack’s case these were not scanned and stored which hampered the investigation and inquest. There remains a risk that where paper records are kept information is not properly recorded, stored or audited. Portsmouth Hospitals University NSH Trust 1. Handover on arrival I heard that there is no specific structure in place at Queen Alexandra Hospital Emergency Department for ensuring the full and accurate handover of information about a patient who arrives whilst subject to detention under the Mental Health Act. I heard evidence that the receiving staff are not required to ask about a patients history of absconding or self harm. This gives rise to the possibility of a patient’s risk not being properly assessed. It was accepted in evidence at inquest that the hospital has a duty of care for all persons on it’s premises and not just those who have been formally admitted as patients. In written submissions after the inquest hearing the hospital have stated that risks of absconding and self-harm are managed by the escorting mental health team. This does not, in my view, absolve them of responsibility for managing these risks whilst the patient is present at their site. 2. Flagging of risk I heard in evidence that it is possible for patient risks to be ‘flagged’ within the Oceana records system to ensure that all staff are made aware of these. This was not done in Jack’s case and that this was not done as a matter of course, The Acting Medical Director was not aware of an established policy or procedure about using this existing functionality. 3. Risk assessment tool A ‘Mental Health Primary Disturbance Survey’ tool was used to assess Jack on his arrival at ED. This indicated that his risk level was ‘level 5+ black’ and this in turn set out a requirement of the mandatory presence of security guards. However when Jack absconded there was evidence that no security guards were present. There was evidence that clinicians made risk based decisions that such guards were not necessary. However I heard evidence that the hospital board were not aware of this tool mandating a security presence and that the tool outcomes were not reflected in trust policies about the risk of absconding. The Acting Medical Director has stated that this tool requires assessment as to whether it is fit for purpose. 4. Paper and electronic records There were records kept during Jack’s presence at Queen Alexandra Hospital which were either not stored or had been lost prior to the inquest. This Regulation 28 – After Inquest Document Template Updated 30/07/2021 significantly hampered the investigation and restricted the information available to the jury. I accept that the location of patients with mental health issues whilst awaiting transfer to a mental health unit has changed since Jack’s death. I also understand that mental health nursing records are now kept within an Enhanced Care Plan but this is still in a paper format and therefore the risk of inadequate information sharing and failing to store records remain. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 by November 09, 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 to the following Interested Persons The family of Jack Farrington I have also sent it to Midlands Partnership Foundation Trust Equans who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 9 Dated: 14/09/2023 Robert SIMPSON Assistant Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Trust Headquarters F Level, Queen Alexandra Hospital Southwick Hill Road Cosham PORTSMOUTH, PO6 3LY 08 January 2024 Dear Mr Simpson, Response to Regulation 28 report to prevent future deaths following the inquest into the death of Jack Farrington dated 14th September 2023, received by the trust on November 9th, 2023 I write to provide the Trust’s response to the regulation 28 report issued following the inquest into the death of Jack Farrington. For ease of reference the matters of concern identified by you in relation to Portsmouth Hospitals University NHS Trust (PHU) during the inquest, as described in the report, are set out below in italics with PHU’s response underneath each concern. 1. Handover on Arrival I heard that there is no specific structure in place at Queen Alexandra Hospital Emergency Department for ensuring the full and accurate handover of information about a patient who arrives whilst subject to detention under the Mental Health Act. I heard evidence that the receiving staff are not required to ask about a patient’s history of absconding or self- harm. This gives rise to the possibility of a patient’s risk not being properly assessed. It was accepted in evidence at inquest that the hospital has a duty of care for all persons on its premises and not just those who have been formally admitted as patients. In written submissions after the inquest hearing the hospital have stated that risks of absconding and self- harm are managed by the escorting mental health team. This does not, in my view, absolve them of responsibility for managing these risks whilst the patient is present at their site. Trust Response: The Trust agrees that the accurate handover of care and risk refers to the transfer of information and responsibility for a patient from one health care professional or team to another. In the context of patients detained under the Mental Health Act, we recognise that whilst responsibility for the patient remains the same, there is a need to effectively communicate and share information about the patient’s care and potential risks. This ensures continuity of care and enables the receiving team to be aware of specific risks or considerations to the patient’s detention under section. Whilst PHU is not a provider of specialist mental health services, specialist support is provided by our partner mental health organisations on an in-reach basis. The patient at the time of his attendance was accompanied on a 1:1 basis by a Solent NHS Trust member of staff in accordance with his Section 17 leave requirement, with verbal handover on arrival by the attending South Central Ambulance Service to the Emergency Department (ED). This handover, as per Professional Record Standard Body (PRSB) Ambulance handover to Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986 emergency care standard 2019, is standard and expected practice which will include the reason for attendance and any potential risks associated with the admission. The Trust uses a Mental Health Primary Risk Assessment Survey Tool to assess patients on arrival to ED, this has been updated following this incident (see response to Q3). In addition, the use of a standardised handover triage and risk assessment tool are in review to ensure that patients’ risk of self- harm or absconding are considered at the point of handover. A meeting has been arranged with Solent NHS Trust on 9 January 2024 to review transfer of care priorities which will include clinician to clinician discussion prior to a patient’s transfer to the Emergency Department. In addition to a proposed clinician-to-clinician discussion, our colleagues at Solent NHS Trust are working on developing an electronic handover system. This system will provide the ED team with more information about the patient's needs and risks before they arrive. We will agree the timeline for implementing this system at the scheduled meeting on January 9, 2024. 2. Flagging of Risk I heard evidence that it is possible for patients’ risks to be ‘flagged’ within the Oceano records system to ensure that all staff are made aware of these. This was not done in this case and that this was not done as a matter of course. The Acting Medical Director was not aware of an established policy or procedure about using this existing functionality. Trust Response: We can advise that since the death of Jack Farrington the flagging of patients with a mental health requirement in the ED now occurs at the department’s safety huddle which takes place every 2 hours throughout a 24-hour period. During this huddle, the department’s senior team highlight patients with a mental health requirement discussing: 1) Identification (patients presented with a mental health concern who are at risk) 2) Assessment (discuss the department's current concern for these patients including any immediate risks or crisis situations) 3) Resources (identifying available resources to support including the mental health liaison team) 4) Safety measures (considering any additional safety measures that may be required i.e., 1:1 supervision, removal self-harm objects and appropriate environment for assessment). The Trust Oceano System does have the facility to flag patients with specific needs, however there are challenges in the visibility of this for clinical staff. The Trust is undertaking an improvement programme for the way our electronic systems are used to ensure that they link with each other to flag patient needs and risks. This programme is being led by our Chief Nursing Information Officer in conjunction with divisional clinical and IT leads. This work, which is in development, will include a Trust Alert Policy and Standard Operating Process (SOP) for the use of alerts and is aimed to be in place by April 2024. We are currently addressing the specific mental health flag requirement within the ED. We are developing a local Standard Operating Procedure (SOP) that will provide guidance to clinical staff on the appropriate use of the flag. Our goal is to have this SOP in place by February 2024. Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986 The Trust is currently in the final stages of recruiting a senior lead for mental health. Once this individual is appointed, they will be responsible for overseeing the progress of this work stream. We are pleased to inform you that the successful candidate will assume the role no later than April 2024. 3. Risk Assessment Tool A “Mental Health Primary Disturbance Survey” tool was used to assess Jack on his arrival at ED. This indicated that his risk level was ‘level 5+ black’ and this in turn set out a requirement of the mandatory presence of security guards. However, when Jack absconded there was evidence that no security guards were present. There was evidence that clinicians made risk-based decisions that such guards were not necessary. However, I heard evidence that the hospital board were not aware of this tool mandating a security presence and that the tool outcomes were not reflected in trust policies about the risk of absconding. The Acting Medical Director has stated that this tool requires assessment as to whether it is fit for purpose. Trust Response: We can confirm that the Trust has undertaken a full review of the Mental Health Primary Disturbance Survey in accordance with Acute Psychiatric Emergency guidance (APEx) and the Royal College of Emergency Clinicians Mental Health in Emergency Departments guidance (2023) updating the tool to reflect best practice guidance for enhanced observation requirement. The tool includes a clear guidance for escalation of concerns to senior nursing staff for support, this includes night-time and out of hours available support. The Trust has also introduced a twice daily Plan of Care Mental Health Huddle which is led by senior nursing staff and attended by all divisions and the in reach Southern Health NHS Foundation Trust Mental Health Liaison Team. The risks and plans for all Mental Health patients in the hospital, including the ED, are reviewed to ensure the best possible allocation of specialist nursing support is in place. The Mental Health Liaison Team is also available to provide guidance to staff out of hours. The allocation of security personnel to support the care of mental health patients is situation and case specific and may vary dynamically for any given individual patient. This is assessed by the local clinical team with support from the Mental Health Liaison team and regular review in the Mental Health huddle. As was discussed at the inquest, the presence of security staff can at times be provocative for Mental Health patients and cause an escalation in their distress and resultant behaviours. A collaborative approach is necessary whereby security staff work closely with mental health professionals and clinical staff to ensure a coordinated and appropriate response to patient needs, supported by risk assessments to ensure their safety and the safety of staff. 4. Paper and electronic records There were records kept during Jack’s presence at Queen Alexandra Hospital which were either not stored or had been lost prior to the inquest. This significantly hampered the investigation and restricted information available to the jury. Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986 I accept that the location of patients with mental health issues whilst awaiting transfer to a mental health unit has changed since Jack’s death. I also understand that mental health nursing records are now kept within an Enhanced Care Plan, but this is still in paper format and therefore the risk of inadequate information sharing and failing to store records remain. Trust Response: As noted by the coroner, the Trust continues to work to improve its processes regarding the care and documentation of the care of patients with mental health needs. Patients awaiting mental health placement are predominantly cared for in the Acute Medical Unit (AMU) with the recent introduction of the mental health nursing records being located within the Enhanced Care Plan. Within the ED, bank and temporary members of staff are provided with a temporary ICT login, and a login for Oceano allowing for electronic documentation of patient assessment and delivery of care. Our partner organisations, Solent NHS Trust, and Southern Health Foundation Trust mental health teams, also now have access to Oceano allowing them to input their assessments and plan of care directly into the Trust’s ICT system negating the need for paper records. The Trust fully agrees that the current hybrid between paper and electronic records creates greater complexity and inefficiency, impacting the ability of the multidisciplinary teams to locate all necessary information for each patient. The ambition of PHU and similar NHS Trusts who have not already done so is to move to a true paper free Electronic Patient Record (EPR). We are working with the Integrated Care Bord (ICB) and other Acute Trusts in Hampshire and Isle of Wight to achieve that goal over time. 5. Partnership Working in the care of patients with significant mental health needs The Trust acknowledges that addressing the needs of patients with significant mental health requirements is an ongoing and growing challenge throughout our healthcare system. Although the Trust does not offer specialised mental health services, we have observed a rising number of patients seeking care who are not suitable for the acute hospital environment. We are committed to continuing to work closely with our partner organisations to provide the best possible outcomes for patients with mental health needs who access our acute care services. The Trust hosts a Mental Health Coordinating group which meets bi–monthly in partnership with our system colleagues to review ways to improve the pathway and experience for patients. This group reports into the PHU Mental Health Operation Board which is chaired by the Deputy Medical Director and has membership from across our health and care system partners. I hope the content of this letter provides the assurance required to demonstrate that the Trust is aware of, and responding to, those issues of concern raised in the regulation 28 report. If you have any further questions, then please do not hesitate to contact me. Yours Sincerely Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986 Chief Executive Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986
Private & Confidential Mr Simpson Coroner’s Office The Castle Castle Hill Winchester SO23 8UL 18th December 2023 Dear Mr Simpson, Mental Health Services 8F The Pompey Centre Fratton Way Portsmouth PO4 8TA www.solent.nhs.uk Regulation 28 Report to Prevent Future Deaths Thank you for providing your concerns to Solent NHS Trust in relation to the investigation into the death of Mr Jack Farrington. The Mental Health Service has fully reflected on the concerns that have been raised and has further reviewed the plans and processes that are currently in place to provide safe care for patients in the charge of the service in view of your concerns regarding our inpatient nursing handovers and management of paper and electronic records. I am now in a position to update you on our actions to date and plans to resolve the issues. 1. Handovers Solent NHS Trust’s Mental Health Service has previously used paper-based handovers, with information populated from clinical records held in SystmOne including legal status, current presentation and risks. This information is manually transferred to the paper sheet. These are currently being stored on the Trust’s IT system. Work is continuing to transfer the handover from a Word document onto SystmOne. This was due to be completed by 01st October 2023, however due to changes in key staff members undertaking this change and the handover document provided on SystmOne that is in use in other clinical areas of Solent not being suitable for use in an acute psychiatric ward, there has been a delay to progress. Work is underway and expected to be completed, with staff trained in its use by the Clinical Practice Education Team by the end of January 2024. I am regretful that the service has not been able to deliver this change in handover process by the date previously proposed in my Witness Statement dated 09th August 2023. If HM Coroner would find it useful, I can provide a further update at the end of January when the SystmOne handover is live and in use. In order to mitigate the risk that the continued use of the handover outside of SystmOne presents, our Clinical Leadership Team are attending handovers to ensure good quality conversation and accuracy of information handed over and undertaking a quality audit of the clinical records. The outcomes from audits are then presented at the Inpatient Governance Meeting and can be escalated to the Mental Health Service Senior Leadership Team at Integrated Governance Meeting if required. Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Road, Southampton, SO19 8BR Telephone: 0800 013 2319 (safehaven) Website: www.solent.nhs.uk Twitter: @SolentNHSTrust Facebook: Solent NHS Trust 2. Paper & Electronic Records The Mental Health Service continues to record various clinical observations on paper-based forms, which are scanned into SystmOne. This includes therapeutic engagement and observations, physical observations, food and fluid charts. The service is working towards replacing the paper-based forms with an electronic form that feeds directly into SystmOne, and I am pleased to report that work is on track and planned to be implemented by 01st April 2024. The Service’s Clinical Matron has visited departments within Southern Health NHS Foundation Trust to view the system in use and is meeting regularly with Solent NHS Trust Information Specialist to ensure this will be ready to implement on time. This change also involves the procurement of tablets to record the information on, which will be tested in all areas of the wards. I hope that my letter has addressed the concerns raised from Mr Farrington’s inquest. I have noted that there were concerns addressed to both NHS England and Portsmouth Hospitals University NHS Trust in addition to Solent NHS Trust. I am pleased to report that our service has been working with Portsmouth Hospitals University NHS Trust to address the concern raised regarding handover on arrival at the Emergency Department and will continue to support Portsmouth Hospitals University NHS Trust in future developments and care arrangements for our shared patient groups. Yours sincerely, Head of Quality & Professions – Mental Health Services Cc: , Chief Nurse – Solent NHS Trust Chief Medical Officer – Solent NHS Trust Page 2 of 2 Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Road, Southampton, SO19 8BR Telephone: 0800 013 2319 (safehaven) Website: www.solent.nhs.uk Twitter: @SolentNHSTrust Facebook: Solent NHS Trust
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