Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0448, written 10 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Nov 2023 |
|---|---|
| Reference | 2023-0448 |
| Deceased | Claire Homer |
| Coroner | Harry Lambert |
| Coroner area | Inner North London |
| Category | Other related deaths |
| Organisation named | Camden and Islington 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: Prevention of Future Deaths report Claire Elizabeth HOMER (died 05.05.23) THIS REPORT IS BEING SENT TO: The Medical Director, CEO and Legal Department of: Camden and Islington NHS Foundation Trust St Pancras Hospital 4 St Pancras Way London NW1 OPE 1 CORONER I am: Harry Lambert Assistant Coroner Inner North London Poplar Coroner's Court 127 Poplar High Street London E14 0AE 2 CORONER'S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On 23 My 2023 an investigation was commenced into the death of Claire Homer aged 46 years. The investigation concluded at the end of the inquest held on 2nd and 11 th November 2023. The Inquest found that Claire Elizabeth Homer suffered from a debilitating constellation of physical, psychiatric and somatic illnesses, with a complex interplay between them. She was found dead in her home on 5 May 2023. Despite Post Mortem examination and toxicology, no cause of death was identified. The medical cause of death was Unascertained . 1 I returned an Open Conclusion. 4 CIRCUMSTANCES OF THE DEATH Please see attached Findings of Fact. 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 fol lows. On the 27 April 2023 Claire's GP, , wrote an email to querying the COAT referral and suggesting family involvement in the sharing concerns around her worsening, formulation of a management plan . Unfortunately there was no reply to this email until 5th May 2023, by which time it was too late. I do not criticise for this, as she was on holiday and thereafter catching up with what was no doubt an avalanche of emails. This does raise the question, however, of whether more robust protocols need to be in place to address the scenarios of (a) patients who are not initially deemed to require handover care but deteriorate during a member of staffs leave and (b) both key points of contact being on leave at the same time. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. 7 YOUR RESPONSE 2 You are under a duty to respond to this report within 56 days of the date of this report, namely by xxx. 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 following. , brother of the Deceased , father of the Deceased • • • Care Quality Commission for England • HHJ Thomas Teague QC, the Chief Coroner of England & Wales 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 other 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 it useful or of interest. You may make he believes may representations to me, the coroner, at the time of your response, about the release or the publication of your response. find 9 DATE 10.11 .23 SIGNED BY ASSISTANT C ~ONER j 3
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.
Partnership Headquarters
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
11th January 2024
Private and Confidential
Harry Lambert
Assistant Coroner
Inner North London
Poplar Coroner’s Court
127 Poplar High St
London E14 0AE
Dear Coroner Lambert
Re Inquest touching the death of Claire Homer (date of death 05/05/2023)
I am writing further to the inquest for Claire Homer which concluded on 11/11/2023 and at which
you issued a Prevention of Future Deaths report. The matters of concern raised were whether
more robust protocols need to be in place to address the scenarios of (a) patients who are not
initially deemed to require handover care but deteriorate during a member of staff’s leave and (b)
both key points of contact being on leave at the same time.
Thank you for raising these points which have been carefully considered from a service
improvement perspective. I can advise that the following actions have now been taken:
1) The importance of ensuring robust ‘Out of Office’ responses when on leave was discussed
with staff in an Early Intervention Service-wide meeting on 24/11/2023. This meeting was
chaired by
service. Staff were asked to ensure their automated ‘Out of Office’ replies clearly signpost
if the matter is urgent or requires an urgent response a) how to escalate a concern and b)
to whom.
, Service Manager. Minutes have since been sent to the whole
2) This has been followed by issuing a template that was circulated on 11/12/2023. Within
this template, it makes clear that if the matter is urgent or requires a more rapid response,
the sender should re-send to the relevant EIS team duty phone (Mon-Fri 9-5pm) and/or the
team email inbox (Mon-Fri 9-5pm). As EIS is not an emergency service, the expected
response time is within 24 hours. Contact details for the crisis line should also be provided
for use in an emergency situation.
Better Mental Health. Better Lives. Better Communities.
3) The service manager has also requested this same practice is robustly followed for
voicemail messages when a member of staff is absent from work.
4) The service manager has checked that the information is correct for both EIS teams online
and has had this amended to include the duty mobile numbers of the two EIS teams, in
addition to the switchboard number and team Inboxes which were already present.
5) With regards key contacts being on leave at the same time, the need for cover
arrangements for doctors to be in place and communicated clearly with the team has been
reiterated. These cover arrangements should always be clearly signposted via ‘Out of
Office’ messages.
6) The service manager has reiterated to team managers the importance of balancing service
need and cover with requests for annual leave.
7) The service manager has reiterated the necessity to provide the team with a clear
handover of patients prior to taking leave. This practice is robustly in place already.
However, when a patient deteriorates whilst they are away, the expectation is that the
person alerting the team to this follows the signposting indicated on their ‘Out of Office’
reply and escalates to the team inbox and/or duty phone.
For the record we wish for it to be noted that in this case staff email accounts have been checked
and robust Out of Office messages were in place signposting recipients to the EIS duty team.
Whilst the above actions are now in place within the EIS team, we will also be ensuring that this
learning is shared and implemented across the Camden division and the wider Partnership.
I trust that this offers you the necessary reassurance in regard to these matters but if you have
any further queries, please do not hesitate to contact me.
Yours sincerely
Chief Medical Officer
Better Mental Health. Better Lives. Better Communities.
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