Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0533, written 19 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2023 |
|---|---|
| Reference | 2023-0533 |
| Deceased | Linda Banks |
| Coroner | Janine Richards |
| Coroner area | County Durham and Darlington |
| Category | Alcohol, drug and medication related deaths |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Trust 1 CORONER , Chief Executive of Tees Esk and Wear Valley Acute NHS I am Janine Richards, assistant coroner, for the coroner area of Durham and Darlington 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 the 19th of April 2022 an investigation was commenced into the death of Linda Louise Banks, aged 48 years. The investigation concluded at the end of the inquest on the 18th of December 2023. The medical cause of death was 1a) Paracetamol overdose with alcohol misuse. I gave a narrative conclusion as follows:- Linda Louise Banks died on the 10th of April 2022 at the University Hospital of North Durham. Linda had a history of alcohol misuse and mental health difficulties, including self harm and suicidal ideation. Linda also had learning difficulties which may have increased her vulnerability, which were not identified by vast majority of the mental health professionals, and there is no evidence that consideration was given to any reasonable adjustments that might be necessary, or as to any impact such may have had on her presentation, communication and understanding. Linda herself, her family and her friends, made multiple contacts with mental health services between February 2022 and her death, as her mental health deteriorated and concerns were expressed as to her safety. Referrals were also made by two external agencies, namely her GP and a home support agency, both expressing concerns about Linda’s presentation. On each occasion risks were considered to be minimal and no further treatment or care was provided by mental health services. There were a multiplicity of difficulties revealed by a serious incident review which was extensively delayed and not received until the end of January 2023, some 9 months after Linda’s death. It concludes that Linda did not receive the right care at the right time and her needs were not fully met, and included concerns, in summary, in relation to the quality of assessments and triage, quality of safety planning, poor record keeping, and further considers that there was an underestimation of risk and a lack of a trauma informed approach. I also find that these difficulties culminated in advice being given to a friend attempting to support Linda and communicated to her family, from an unknown mental health worker, that they should consider “tough love” and to effectively step back from their intensive support of Linda, thus removing an essential safety net in the absence of any ongoing mental health treatment or support. The identified failings cumulatively contributed to the death more than minimally. An earlier thematic review which had been completed in November 2021 identified many similar serious issues in the provision of mental health services, to those identified in this case, and it is clear that many of these issues were continuing at the time of Linda’s death in April of 2022 and had not been addressed effectively by the Trust. On the 9th April 2022 Police forced entry to Linda’s home, as a result of concerns raised by her family and friends and was taken to hospital by ambulance. She was hyperthermic and had low blood sugar and had taken an overdose of medication. Despite attempts to treat her she died in hospital on the 10th April 2022 as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease 4 CIRCUMSTANCES OF THE DEATH Linda Louise Banks died on the 10th of April 2022 at the University Hospital of North Durham as a result of an overdose of paracetamol against a background of alcohol misuse and subsequent to a deterioration in her mental health. 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 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. – (1) A thematic review completed in November 2021 had identified a number of significant issues in the functioning of mental health services, and many of the same issues were also identified in the serious incident review into Linda’s care and treatment, from February 2022 until her death. It is apparent that any actions taken as a result of the thematic review were not effective in implementing change and that the action plan was still a “work in progress” at the Pre Hearing Review Hearings which took place in this case in 2023. (2) The Serious Incident Investigation into the care received by Linda was not completed until the end of January 2023, some 9 months after the death. This is neither timely nor responsive. Despite reassurances given that the Trust are working to eradicate such delays, in response to a series of previous PFD reports issued by the Coroners of Durham and Darlington, there are still cases coming to the attention of the Coronial service where Serious Incident Investigations are significantly delayed in excess of the 60 day NHS framework. (3) As previously reported the concern in relation to the delays in such investigations and any subsequent necessary action required, is twofold. Firstly, the quality of the investigation is severely compromised as the evidence is not captured when memories are fresh. Secondly, because any lessons to be learnt and improvements to be made to improve patient safety cannot be implemented promptly. 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 23.2.24 . 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 family of the deceased. I have also sent it to the Care Quality Commission 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 DATE 19.12.23 HMAC Richards
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.
Office of the Chief Executive West Park Hospital Edward Pease Way Darlington Co Durham DL2 2TS Private and Confidential Ms J Richards HM Assistant Coroner for County Durham and Darlington HM Coroners Office PO Box 282 Bishop Auckland Co Durham DL14 4FY 23 February 2024 Private and Confidential Dear Ms Richards, Just a short note at this stage to acknowledge receipt of your letter dated XXXX 2017 bringing to my attention concerns raised by your above named constituent in respect of XXXXXXX Re: Report to Prevent Future Deaths issued on in relation to Linda Banks I am writing to you in response to the Report to Prevent Future Deaths (PFD) served on Tees, Esk and Wear Valleys NHS Foundation Trust on 19 December 2023 regarding the death of Linda Banks. For ease of reference I have addressed concerns 2 and 3 separately to concern 1: I have asked for an investigation to be carried out into the concerns raised by XXXXX following which I will send a Concern 1: A thematic review completed in November 2021 had identified a number of detailed reply to you. significant issues in the functioning of mental health services, and many of the same issues were also identified in the serious incident review into Linda's care and With kind regards treatment, from February 2022 until her death. It is apparent that any actions taken as a result of the thematic review were not effective in implementing change and that the Yours sincerely action plan was still a "work in progress" at the Pre Hearing Review Hearings which took place in this case in 2023. As advised at the inquest, the action plan for the thematic review was reviewed and incorporated into a larger overarching improvement plan for the Durham and Darlington Crisis Team following a restructure of its operational management and governance processes and arrangements in April 2022. This meant that whilst all the points had been actioned, some work was still being carried out at the time of the Pre-Inquest Review Hearings to continue to Colin Martin refine and improve the Crisis Team and ensure any changes were fully embedded. As heard Chief Executive at the inquest and set out in the statement of Thomas Hurst, all actions have been addressed, with a plan for outstanding training to be completed, however if you wish for further clarity on Date any particular action please let me know. Concern 2: The Serious Incident Investigation into the care received by Linda was not completed until the end of January 2023, some 9 months after the death. This is neither timely nor responsive. Despite reassurances given that the Trust are working to eradicate such delays, in response to a series of previous PFD reports issued by the Coroners of Durham and Darlington, there are still cases coming to the attention of the Coronial service where the Serious Incident Investigations are significantly delayed in excess of the 60 day NHS framework. Concern 3: As previously reported the concern in relation to the delays in such investigations and any subsequent necessary action required, is twofold. Firstly, the quality of the investigation is severely compromised as the evidence is not captured when memories are fresh. Secondly, because any lessons to be learnt and improvements to be made to improve patient safety cannot be implemented promptly. We have taken your concerns regarding the timing of Serious Incident Investigations (SII) very seriously and as you state, I have updated you on the Trust's progress in relation to this on a number of occasions, including regularly providing you with a list of SII that remain outstanding. We have made every effort to be transparent with you and to confirm the clear timelines for completion for internal quality assurance. It was therefore disappointing to receive a further PFD on this matter. I was further confused that the PFD in this case appears to have been issued in relation to you being advised on another unrelated matter that an SII would not be completed until January 2024, when the death occurred in October, and not due to any outstanding concerns in relation to the evidence heard at this inquest. The Patient Safety Incident Response Framework (PSIRF) will replace the current Serious Incident Framework 2015. This represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. This is a key part of the national NHS Patient Safety Strategy, which recognises that new ways of learning are required to drive change and improve standards. PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims: Compassionate engagement and involvement of those affected by patient safety incidents. Application of a range of system-based approaches to learning from patient safety incidents. Considered and proportionate responses to patient safety incidents. Supportive oversight focused on strengthening response system function and improvement. The Trust fully transitioned to the new PSIRF arrangements in January 2024, following months of developing a new set of systems and processes, including the implementation of "InPhase" which is the new mechanism for incident reporting. Under both the 2015 Framework and PSIRF, following the notification of a death, the death is reviewed by the Trust as part of a multidisciplinary huddle. This identifies the most appropriate and proportionate response which under PSIRF includes a wide range of options, such as, but not limited to, a Multi-Disciplinary After-Action Review, a Mortality Review or a Patient Safety Incident Investigation (PSII). We have always undertaken Early Learning Processes in lieu of any further investigation to identify any issues or themes in the period immediately after we are aware of the death. PSIRF has offered a range of options and these systems and processes will further improve the Trust's ability to identify themes early in patient safety incidents and respond in a timely manner, taking actions that are SMART (Specific, Measurable, Assignable, Realistic and Time-related). It is important to note, that PSIRF does not incorporate any specific timescales for completion of PSII reports, recognising each case is individual, however the Trust are aiming to complete these in a timely manner. I continue to have direct oversight of all incident reports, as does the Chief Nurse, who keeps our Quality Assurance Committee and our Board fully briefed on the progress of the remaining cases which fell within the old Serious Incident Framework, in addition to the responses to new incidents under PSIRF. NHS England, the North East and North Cumbria Integrated Care System and the Care Quality Commission also remain fully sighted on these issues. We also continue to have weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. Any patient safety incident that occurred before the implementation of PSIRF will have a review under the 2015 framework, these reviews are all progressing. I have taken the opportunity to share an updated version of the list of the serious incident reviews that I have previously shared with you to be open and transparent and to demonstrate progress. You will see from this that the only case remaining open and ongoing is a complex homicide review being undertaken by an external agency. In light of the above, we hope that you are assured that timely investigations remain a priority for us and we are focused on processes to ensure early memory capture of evidence in addition to identifying and implementing learning promptly. Given the changes around PSIRF, our Chief Nurse would be more than willing to come and talk to you about the new processes, as we have done with other Coroners in the area. Yours Sincerely Chief Executive
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