Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0005, written 20 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 | 20 Dec 2023 |
|---|---|
| Reference | 2024-0005 |
| Deceased | Ryan Evans |
| Coroner | Darren Stewart |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Frimley Health NHS Foundation Trust · Surrey and Borders Partnership NHS Foundation 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. CEO, Frimley Health NHS Foundation Trust (FPH) 2. CEO, Surrey and Borders Partnership NHS Foundation Trust (SABP) 1 CORONER I am Darren Stewart OBE, 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 4th April 2018 I commenced an investigation into the death of Ryan John EVANS. The investigation concluded at the end of the inquest on 23rd January 2023. The inquest was heard with a Jury. Mr. EVANS died of: 1a: Asphyxia 1b: Suspension by the neck The jury returned the following narrative conclusion: Narrative conclusion Ryan John Glyn EVANS was a 20 year old man with a global learning delay (a learning disability) and was registered disabled. He had a diagnosis of depression which dates back to 2016. He was physically fit and was living on his own in assisted living with seven hours of support a week. Ryan was adopted at age two along with his older brother and sister and were brought up in a close family unit with his adoptive parents, following a traumatic early childhood. Ryan was vulnerable due to his learning disability and depression, recent self- harm and attempts of suicide. Ryan's mental health had deteriorated over approximately seven months due to a number of contributory factors. - Notice to leave his accommodation and uncertainty of future living plans. - Finding out the nature of his biological fathers suicide (hanging) via social media - Medication, drugs and alcohol - Breakdown in relationship with ACASA management Ryan John EVANS (26975-2018) Ryan was arrested on 2nd April outside ACASA offices for: -Outstanding criminal damage -Threatening behaviour -Violent / Abusive phone calls Ryan was taken to Frimley Park Hospital by ambulance following collapse in the police van with chest and abdomen pain, his self-harm injuries were dressed and no physical issues were discovered so he was released into police custody. Despite evidence of self-harm, no Mental Health Assessment was carried out at this point. On booking into police custody, Ryan was noticeably upset. He was referred to and visited by a Health Care Professional (HCP) and Hampshire Liaison and Diversion Service (HLDS) at the request of the police custody sergeant. -HCP reviewed his physical condition and redressed his self-harm injury -HLDS failed to document the encounter on the RIO system and only updated the custody record with a screening document. This follows a failure to update the RIO system in January 2018 when Ryan was previously seen by HLDS. There was failure to carry out a Mental Health Assessment and no record of Ryan refusing to be assessed. It could not be concluded that these shortcomings significantly shortened Ryan John Glyn EVANS life. HLDS report screen was completed and uploaded onto the custody record with no reference to a Mental Health Assessment being required or declined by Ryan. Throughout Ryan's stay in custody he expressed suicidal ideations on multiple occasions, spoke to the Samaritans and concerns were raised by family which were reported back to the custody Sergeant. Communication of this information was ineffective. Additionally, across the custody suite there was a sense of complacency with references to Ryan's behaviour being "attention seeking" and no future referrals to HLDS were made. Despite no formal guidance, it is regrettable that on disposal, no verbal handover was done with Ryan's father. It could not be concluded that these shortcomings significantly shortened Ryan John Glyn EVANS life. Ryan was released into the care of his father at approximately 22:30 from Basingstoke Custody Centre. He was in a distressed state over the conditions of his discharge and how he found out about his biological father committing suicide by hanging. Ryan refused to go home to his parents residence and wanted to go to his own accommodation. His father dropped him off around midnight and waited till Ryan was safely in the building. Ryan was found hanging the following morning, 3rd April 2018, by a fellow resident in the communal area of the building. Ryan had a long standing history of depression and several suicide attempts. Ryan John EVANS (26975-2018) Ryan John Glyn EVANS took his own life while suffering from the diagnosed medical illness of depression. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are recorded in the Jury’s Narrative Conclusion. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. The concerns raised were as follows: a. Referral to Psychiatric Liaison Services for patients presenting with self-harm injuries and suicidal ideation (including those in Police custody) at Frimley Park Hospital A&E, including the extent to which the NICE guidance is complied with or provides effective guidance to staff in such circumstances. b. The conduct of Mental Health Assessments in a custody setting by liaison and diversion staff including the adequacy of policy and guidelines relating to triggers to conduct such assessments and the manner in which refusals are dealt with. c. The passage of information both between custody staff, as well as with healthcare staff in relation to concerns of a mental health nature for a detained person including the extent to which the custody record is used as an effective means to communicate concerns/observations of detained persons mental health. d. The process of release of a vulnerable detained person following disposal, including interaction with family or other persons collecting the detained person. I received further evidence in writing from the Interested Persons’ subsequent to the completion of the Inquest in relation to these concerns. This evidence included responses from Hampshire Constabulary and Southern Health NHS Foundation Trust concerning the measures which have been put in place to address the failures identified during the course of the Inquest with respect to concerns at b – d (above). I was satisfied that these measures addressed the concerns in relation to each of these Interested Persons. I also received evidence from the Frimley Health NHS Foundation Trust concerning the measures which that organisation had undertaken in their area of responsibility to address my concern detailed at a (above). This evidence has not allayed my concern in relation to a (above). 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. Evidence received from the police officers accompanying Mr. EVANS during his attendance at Frimley Park Hospital provided that: a. Mr. EVANS presented with a large fresh cut on his arm and also cuts on his Ryan John EVANS (26975-2018) legs which were identified by him as being from self-harm with hospital staff noting that the larger mark on the arm might require stitching. b. Police officers stated that Mr. EVANS was open with hospital staff about his feelings of self-harm depression, and thoughts of ending his own life. Officers further recalled that hospital staff noticed and commented on the self-harm marks on Mr. EVANS’ arms, including whilst staff were dressing a recent self- harm wound on Mr. EVANS’ left arm. c. Officers also recalled Mr. EVANS commenting when offered food by hospital staff that he would rather starve to death. d. One of the accompanying police officers expressed surprise at the fact that Mr. EVANS was not subject to a mental health referral or assessment, in the context of him commenting to multiple hospital staff members about his self-harm actions and ideation. An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self- harm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded. The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: The short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital. These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.” Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation. The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’ I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again. The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment. Ryan John EVANS (26975-2018) 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 29th February 2024. 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 namely: Family of Ryan John Glynn EVANS Hampshire Constabulary , Hampshire Constabulary , Hampshire Constabulary Southern Health NHS Foundation Trust Former SHFT Employee, Registered Mental Health Nurse MITIE , Former MITIE Employee, Health Care Practitioner (HCP) Alexander’s Care and Support Agency (ACASA) IOPC 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 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. 9 20th December 2023 Darren Stewart OBE Ryan John EVANS (26975-2018)
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.
Frimley Park Hospital Portsmouth Road Frimley Camberley GU16 7UJ Tel. www.fhft.nhs.uk 26th February 2024 HM Assistant Coroner Darren Stewart OBE Hampshire Coroner’s Court The Castle Castle Hill Winchester SO23 8UL Dear Mr Stewart I write in response to the Regulation 28 Report you issued on 20th December 2023, following the inquest into the death of Mr Ryan Evans, which concluded on 23rd January 2023. Your concern related to the ‘referral to Psychiatric Liaison Services for patients presenting with self-harm injuries and suicidal ideation (including those in Police custody) at Frimley Park Hospital A&E, including the extent to which the NICE guidance is complied with or provides effective guidance to staff in such circumstances.’ I was deeply saddened by the circumstances surrounding Mr Evans’ death and I would like to pass my sincere condolences to Mr Evans’ family. I hope this letter provides both yourself and the family of Mr Evans some reassurance about the improvements that have been made to the psychiatric liaison referral process since Mr Evans’ death in 2018 and since the publication of the NICE guidance in 2022. Since Mr Evans’ attendance at Frimley Park Hospital on 2nd April 2018 there has been a recognition across the whole of the NHS that much more needed to be done for patients with mental health issues, in particular those patients presenting to Emergency Departments. I hope this letter provides reassurance about the steps taken to prevent future deaths and to ensure that the NICE guideline [NG225] titled ‘Self – harm: assessment, management and preventing recurrence’ (September 2022) has been complied with and is providing effective guidance to staff in the Emergency Department at Frimley Health NHS Foundation Trust. Updated Emergency Department Triage Process Paragraphs 1.7.12 – 1.7.14 of the NICE guideline [NG225] states: ‘When a person attends the emergency department or minor injury unit following an episode of self-harm, emergency department staff responsible for initial assessment or triage should establish the following as soon as possible: - the severity of the injury and how urgently physical treatment is needed Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital In partnership with the Ministry of Defence - the person's emotional and mental state, and level of distress - whether there is immediate concern about the person's safety - whether there are any safeguarding concerns - - the person's willingness to accept medical treatment and mental healthcare the appropriate nursing observation level - whether the person has a care plan. 1.7.13 When a person attends the emergency department or minor injury unit following an episode of self-harm, offer referral to age-appropriate liaison psychiatry services, or for children and young people, crisis response service (or an equivalent specialist mental health service or a suitably skilled mental health professional) as soon as possible after arrival, for a psychosocial assessment (see the section on psychosocial assessment and care by mental health professionals and the section on risk assessment tools and scales), and support and assistance alongside physical healthcare. 1.7.14 An age-appropriate liaison psychiatry professional or a suitably skilled mental health professional should see and speak to the person at every attendance after an episode of self-harm.’ In response to this NICE guideline and additional guidance from the Royal College of Emergency Medicine (RCEM); ‘Mental Health in Emergency Department’s – A Toolkit for Improving care’, April 2021, the Trust has now updated its digital triage assessment of all patients attending the Emergency Department to include a mandatory question about a patient’s history of mental health and/or self-harm. This question is asked of all patients attending the Emergency Department within 15 minutes of their arrival regardless of the reason for their presentation. Whenever a patient reveals a history of mental health issues or self-harm, either by overt presentation or by disclosing it when asked at triage, a further mental health assessment is undertaken by a nurse within the Emergency Department. Please find attached a copy of the Mental Health Triage Tool now used in the Emergency Department. The mental health assessment now undertaken will assess the patient’s immediate level of risk, their risk of abscondence and the level of their need for enhanced care to support their attendance. This will guide the clinician completing it as to whether a referral to Psychiatric Liaison Services is necessary. Based on the outcome of the triage, the clinician will contact Psychiatric Liaison Services to discuss the attendance and seek further guidance. This contact can either be over the phone or in person (Psychiatric Liaison services now have a presence at Frimley Park Hospital 24 hours a day, 7 days a week, 365 days a year.) Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital In partnership with the Ministry of Defence If necessary, following this discussion, a referral will be made to Psychiatric Liaison services and a private area of the Emergency Department will be made available, as recommended at paragraph 1.7.15 of the NICE guideline [NG255]. In February 2019 Surrey and Borders Partnership NHS Foundation Trust, the provider of Psychiatric Liaison services at Frimley Park Hospital’s Emergency Department, introduced an Operational Policy for the Psychiatric Liaison referral services it provides to a number of acute Trusts including Frimley Health NHS Foundation Trust (copy attached). At page 8 of the Operational Policy sets out: ‘Any concerns regarding mental health should be discussed with the Psychiatric Liaison Team. The team will discuss and prioritise referrals based on clinical need and will respond accordingly to offer advice, review, face to face assessment or consultation based on clinical requirement. Presentations for referral may include (but not limited to): - self–harm - co-morbid physical and mental health problems e.g. depression - dementia - delirium, with or without dementia - medically unexplained symptoms - suicidal ideation - psychosis’ The Operational Policy also sets out at page 4 that any referral from the Emergency Department will be by its very nature an emergency referral and that whilst every referral will need to be triaged to assess for urgency the target is for Psychiatric Liaison services to act upon the referral within 60 minutes of receipt. A review of the monthly audits reveal that over 90% of all referrals are acted upon in less than 60 minutes. The Operational Policy has been shared with staff working within the Emergency Department at Frimley Health NHS Foundation Trust and the updated referral form is held on the Trust intranet. In summary, if a patient such as Mr Evans were to attend the Emergency Department at Frimley Park Hospital today presenting with recent self- harm and expressing an intention to commit further self- harm, in line with NICE and RCEM guidance, they would be immediately referred to Psychiatric Liaison services for an in-depth psycho-social assessment. Training Clinicians in the Emergency Department are now provided with training on mental health triage assessment during their induction and go on to shadow other staff completing the mental health triage assessments before carrying them out independently. The Trust has also signed up to a mental health skills module for nurses which began last year and is facilitated by New Buckinghamshire University. Twenty students have completed the 12-week, level 7 training and will work as mental health champions in their respective areas. Thirty more nurses will attend this training in March 2024. Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital In partnership with the Ministry of Defence Several bespoke training programmes are also facilitated through the Trust’s ‘Diverse Needs Programme’, part of which covers training on ‘Mental Health in Acute Settings’. Collaboration with other services In accordance with paragraph 1.1.17 of the NICE guideline [NG255] Frimley Park Hospital and Surrey and Borders Partnership ensure that appropriate joint governance arrangements are in place so that physical and mental healthcare can be delivered together in the emergency department at Frimley Park Hospital. As set out in the NICE guideline this includes the following: - access to electronic record systems for both mental health services and medical treatment at the point of care - - jointly agreed referral pathways for concurrent physical and mental healthcare jointly agreed approaches to initial assessment and triage - monitoring of the use of mental health law and mental capacity law - - - joint safeguarding procedures jointly agreed nursing observation policies referral pathways to appropriate community services. Teams from Psychiatric Liaison services from Surrey and Borders Partnership, the Emergency Department at Frimley Park Hospital and Surrey Police have monthly meetings to discuss the practical points of the working relationship, the referral process, and evolving issues and themes. This is attended by the Deputy Chief Nurse and the Trust lead for Mental Health. A further Mental Health Steering Group meeting is undertaken every two months with a standard template agenda based around the recommendations listed at paragraph 1.1.17 of the NICE guidance. This includes specific discussion and sharing of information between and across services regarding training needs and compliance, incident learning and escalation, audit, and policy availability and adherence. Themes of the meeting are then escalated into the Executive Safeguarding and the Mental Health Committee which ultimately reports to the Care Governance Committee and the Trust Board. Both the initial Emergency Department triage and the mental health assessment form are now held electronically on the Trust’s electronic patient record, to which the Psychiatric Liaison services team have access. This means that, if necessary, a patient’s entire medical record can be referred to by Psychiatric Liaison services. Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital In partnership with the Ministry of Defence Once again, I am very sorry for what happened, and the gaps identified in the care of Mr Evans. I hope that this provides the assurance that you will need on the actions we have taken but if I can be of any further assistance, please do not hesitate to contact me. Yours sincerely Chief Executive Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital In partnership with the Ministry of Defence
28 February 2024 Private and Confidential Mr Darren Stewart OBE Assistant Coroner for Surrey Sent by email: Chief Executive Chief Executive’s Office Surrey and Borders Partnership NHS Foundation Trust 18 Mole Business Park Randall’s Road Leatherhead KT22 7AD Dear Mr Stewart Ryan Evans (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 20 December 2023, in relation to the inquest touching the death of Ryan Evans. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues from the relevant divisions. In the PFD report, you highlighted a concern relevant to the Trust and Frimley Health NHS Foundation Trust (“Frimley”). In particular, you outline the additional evidence provided at the inquest by Frimley Health NHS Foundation Trust. We believe that the Trust did have adequate measures in place at the time of Mr Evans’ admission to Frimley Park Hospital and that, had we received a referral, we would have responded in a timely manner. We were not present at the inquest to hear the additional evidence referred to as the Trust was not an Interested Person, nor was any member of staff asked to provide oral evidence. We were not therefore advised of the date of the inquest or aware of these concerns until receipt of the PFD Report. Had we been aware of your concerns at the time that the Prevention of Future Deaths evidence was heard (which we understand both Frimley and Southern Health NHS Foundation Trust were invited to provide), we would have been very willing to seek to provide you with assurance as to the processes for referral from the Emergency Department (“ED”) to our Psychiatric Liaison Services (“PLS”) based in the ED. The Trust is commissioned to provide the PLS within Frimley Park Hospital. This includes all wards within the hospital, of which the Emergency Department is one. The PLS team has developed close working relationships with the clinicians operating across the hospital. We are confident that the Trust has a robust process for referral and assessment of people presenting with mental health needs at Frimley Park Hospital. The PLS Standard Operating Policy also sets out guidance to assist those working at Frimley Park Hospital determine when a referral may be appropriate. This includes where a person presents with self-harm and suicidal ideation. We are aware Page 1 of 2 that the Emergency Department at Frimley Park Hospital has introduced changes to their triage system in accordance with NICE and Royal College of Emergency Medicine (RCEM) guidelines, which we support. As part of our continuous improvement work, we are constantly reviewing the PLS referral criteria. The Standard Operating Policy (dated February 2019) was most recently updated and ratified in October 2023. The Mental Health Lead at Frimley Park Hospital provided input as part of this process. The referral criteria provides guidance to clinicians but cannot prescribe for every scenario that may be presented. This is attached, as an aide memoir, to the referral form. The referral form allows for sufficient information to be shared with the PLS clinician assessing the referral. There is a low threshold for acceptance of referrals. Exercise of clinical judgment and relationships between the PLS and clinicians at Frimley Park Hospital are important aspects of decision making in this context. PLS clinicians attend a monthly meeting with Emergency Department clinicians and Surrey Police which is an opportunity to discuss complex referrals and other issues such as identification of training needs. This collaborative working has enabled better understanding of mental health needs and the role of PLS as part of this. Recognising the challenges presented by people attending the Emergency Department with physical and mental health needs, the Trust is also currently working with Frimley (as well as all four other acute NHS Trusts within Surrey) as part of the Surrey Heartlands Mind & Body Programme. This includes current work on the Enhanced Clinical Framework which is designed to promote a culture of excellence, continuous learning, and patient-centred care relating to people presenting with mental health needs in acute hospitals. The framework provides guiding principles and the bedrock to help improve access, experience and outcomes. We are aware that a mental health skills module for nurses working at Frimley began last year, facilitated by New Buckinghamshire University. Twenty students completed the 12 week level 7 training and they will work as mental health champions in their respective areas. There is space for 30 students for the next cohort which will start in March 2024. On behalf of the Trust, I would like to offer our sincere condolences to Mr Evans’ family for their loss. Yours sincerely, Chief Executive Page 2 of 2
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