Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0026, written 26 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 | 26 Sep 2023 |
|---|---|
| Reference | 2024-0026 |
| Deceased | Benjamin Hazelden |
| Coroner | Catherine Wood |
| Coroner area | North East Kent |
| Category | Suicide (from 2015) · Railway related deaths |
| Organisation named | East Kent Hospitals University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
2.
, Chief Executive NHS Kent and Medway Clinical
Commissioning Group
, Chief Executive NHS England
1
CORONER
I am Catherine Wood, assistant coroner, for the coroner area of North East Kent.
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On the 21 February 2022 an inquest was opened into the death of Benjamin Henry
Hazelden. At the inquest, which was a wider article 2 compliant inquest and lasted four
days the court heard from several of those involved in Benjamin’s short life, I concluded
on 13 July 2023 with a narrative conclusion “Ben died as a consequence of his own
actions during an episode of disturbed dissociative behaviour whilst waiting for a
specialist bed to be procured in the community as a consequence of a failure to procure
and provide a suitable inpatient bed to meet his needs.”
4
CIRCUMSTANCES OF THE DEATH
1. Ben Hazelden had a complex history including dyspraxia, autistic spectrum
disorder, anxiety with depression and post traumatic stress disorder, the latter
being due to having been abused earlier in his life. He suffered from dissociative
episodes where he had at times harmed himself and others but otherwise was
engaging and well-liked by those who met him. He was also in the process of
seeing a neurologist given a family history of Huntingdon's disease. He was
admitted to hospital as a 17 year old and transferred to adult services on reaching
18. A package was put in place for him to be transferred to the community with
support from a private care provider with two members of staff being with him
24hours a day in March 2021. He initially did well and had also been seen by a
psychologist from Kent and Medway Complex Autism service and was undergoing
some therapy with a view to reducing his risk and stabilisation of his presentation
prior to considering any long term trauma work. He had a deterioration in his
mental health in July 2021 and was admitted under the provisions of the Mental
Health Act to St. Martin's hospital in Canterbury.
2. He returned home in August and the dissociative incidents continued but were
manageable until the end of the year when there were concerns over the
increasing frequency and risks. In January 2022 he had taken himself onto train
tracks near his house and was taken to the Queen Elizabeth the Queen Mother
hospital and assessed by liaison psychiatry who did not consider he had an acute
treatable mental health problem. He stayed at Queen Elizabeth the Queen Mother
hospital whilst discussions ensued between the agencies involved in his care
including Kent County Council, Kent and Medway NHS and Social Care
Partnership Trust, Avondale, the Integrated care board and East Kent hospitals
NHS Trust. Attempts were made to obtain a specialist bed and a Mental Health
Act assessment on 28th January 2022 deemed him not to be detainable under
the provisions of the Mental Health Act although the possibility of an informal bed
was suggested as an interim solution. Ultimately it was decided that he should be
discharged home with an increased package of care and now 3 carers.
3. He went home on 3rd February and on 11th February he assaulted two members
of staff and ran to the nearby train station placing himself on the tracks where
sadly a train coming into the station hit him. He died from his injuries at the scene.
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.
In the course of hearing the evidence it was clear that young adults with autism
who were at risk of self-harm as well as harm to others have very limited options
in terms of placements where their needs can be met. A bespoke placement
had been carefully created by those involved in Ben’s care but this had taken
several months to arrange. This arrangement had worked well and all involved
tried to make it a success and for quite some time it was. It was however
recognised that there may come a time in the future when his risks to himself
and others would mean an alternative placement would be needed.
2. When Ben’s risks to himself increased further there were no suitable beds
available where he could be cared for in an environment which could meet his
needs. He spent several days in an acute hospital bed despite being medically
fit for discharge which although, essentially a place of safety, was totally
unsuited to his needs. This stay continued whilst discussions ensued regarding
where he should be placed. A bed in an acute psychiatric ward was considered
but not deemed appropriate to meet his needs and as there were no specialist
beds available he was discharged back to his home with increased support as
the best option available. Had a bed been available in a specialist unit it is likely
that he would not have died when he did.
3.
In the evidence provided it became clear that a lot of units where a specialist
bed may have been available had been closed in the past due to concerns
about the level of care following a number of investigations. This has led to a
system whereby locally and nationally there are limited options for those
requiring care relating to both the management of autism and self-harm or harm
to others, particularly when there is an urgent need for increased support. Whilst
the inquest heard there were some counties who had specialist beds they were
difficult to access as they were often full and places were not always available to
meet urgent needs
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 22 November 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 namely the family, Avondale Care, Kent County Council, Kent and Medway
Commissioning Group, East Kent Hospitals NHS Trust, and Kent and Medway
Community Partnership NHS Trust.
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
26 September 2023
Catherine Wood
Assistant Coroner
North East Kent
The office of the Chief Nursing Officer NHS Kent and Medway 2nd Floor, Gail House Lower Stone Street Maidstone Kent ME15 6NB www.kentandmedway.icb.nhs.uk Private and confidential Ms Catherine Wood Assistant Coroner North East Kent Coroners Cantium House, 2nd Floor Maidstone Kent ME14 1XD Sent via email 29 November 2023 Dear Ms Wood, Regulation 28 Report regarding Benjamin Henry Hazelden I write in response to the Prevention of Future Death Report dated 26th September 2023 sent pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death of Benjamin Hazelden on 11th February 2022. During the inquest, you heard evidence giving rise to the following concern(s): 1. In the course of hearing the evidence it was clear that young adults with autism who were at risk of self-harm as well as harm to others have very limited options in terms of placements where their needs can be met. A bespoke placement had been carefully created by those involved in Ben’s care, but this had taken several months to arrange. This arrangement had worked well, and all involved tried to make it a success and for quite some time it was. It was however recognised that there may come a time in the future when his risks to himself and others would mean an alternative placement would be needed. 2. When Ben’s risks to himself increased further there were no suitable beds available where he could be cared for in an environment which could meet his needs. He spent several days in an acute hospital bed despite being medically fit for discharge which although, essentially a place of safety, was totally unsuited to his needs. This stay continued whilst discussions ensued regarding where he should be placed. A bed in an acute psychiatric ward was considered but not deemed Chair | Chief Executive | appropriate to meet his needs and as there were no specialist beds available he was discharged back to his home with increased support as the best option available. Had a bed been available in a specialist unit it is likely that he would not have died when he did. 3. In the evidence provided it became clear that a lot of units where a specialist bed may have been available had been closed in the past due to concerns about the level of care following a number of investigations. This has led to a system whereby locally and nationally there are limited options for those requiring care relating to both the management of autism and self-harm or harm to others, particularly when there is an urgent need for increased support. Whilst the inquest heard there were some counties who had specialist beds they were difficult to access as they were often full, and places were not always available to meet urgent needs. As all three of the concerns that you have highlighted in the Regulation 28 Report appear to relate to the same issue, i.e., the need, availability, or access to an “alternative placement”, “bed in a specialist unit” or “specialist bed”, (all of which I understand to mean a hospital bed), I will respond to all concerns together. In doing so I will not repeat the written and oral evidence provided to the Court during the inquest by (Associate Director for Learning Disability and Autism) highlighting the challenges in commissioning specialist beds for autistic people whilst delivering on national policy requirements to reduce reliance on hospital care and treatment for autistic people with needs such as Mr Hazelden’s. Kent and Medway ICB is currently involved in a project with colleagues in Sussex ICB and Surrey ICB to scope options for the provision of specialist in-patient beds for people with learning disability and for autistic people across the Kent, Surrey, and Sussex footprint. Commissioning specialist in-patient services across this broader geographical footprint provides critical mass of patient need and economies of scale which cannot be achieved by one ICB alone due to the reduced need for such services as a result of implementing national policy. PA Consulting, a private consulting firm, have been commissioned by Sussex ICB to develop and present proposals for specialist in-patient services by the end of March 2024 (Phase 1) for the three ICBs to consider and consult on with autistic people and other stakeholders (Phase 2) and implement collaboratively (Phase 3). Based on the above, I hope I have provided you with the relevant assurance that Kent and Medway ICB has taken your concerns seriously and we will continue to strive to provide an appropriate range of services to autistic people and to offer high standards of care to our patients. Yours sincerely Interim Chief Nursing Officer NHS Kent and Medway Page 2 of 2
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