Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0060, written 5 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Feb 2024 |
|---|---|
| Reference | 2024-0060 |
| Deceased | Paz Ogbe-Millar |
| Coroner | Tony Murphy |
| Coroner area | London (North) |
| Category | Railway related deaths |
| Organisation named | West Hertfordshire Teaching Hospitals NHS Trust · Hertfordshire Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chier Executive West Hertrorashire Hospitats NHS Trust Wattorad Genera Hospital Vicarage Road Hertfordshire WD18 OHB 1 | CORONER | am Mr P.A. Murpny, Area Coroner ror tne coroner area of tne Nortnern District or Greater Lonaon 2 | CORONER’S LEGAL POWERS | make tnis report unger paragrapn /, Scneaute 5, of tne Coroners ana Justice Act 2009 and regulations 28 ana 29 or tne Coroners (Investigations) Regutations 2013. 3 | INVESTIGATION ana INQUEST On tne 3ra of Decemper 2021 an investigation was opened into tne aeatn of Mr Paz Ogne Minar. On tne 4tn January 2022 an Inquest was opened, which concluded ata final hearing before me on 21 Octoner 2022. The conclusion of the inquest was that Mr Ogve-Minar Intentionally took his own life by jumping In front of a moving train wnile suffering from a relapse in cannabis induced Psychosis and tnatthis outcome was contributed to by the following factors: (a) Tne decision py tne Community Menta: Heattn Team to aiscnarge Mr Ogne-Mmar from its service on 30 November 2021; (v) he absence of an adequate system at the Emergency Department to record ee Information provided bythe police to the nospital staff regarding Mr Ogve-Millar’s risk of self-narm, (c) Tne aecision by the Emergency Department not to alow Mr Ogpve-Millar’s mother to remain with him in the nospital, pending tne arrival of the Menta: Heaitn Liaison eam; (a) Problems surrounding the system for making referrals to the Menta: Hearn Liaison eam; (e) Tne decision of tne Emergency Department not to go outsiae with Mr Ogne-Minar when he sald he was going outside to smoke after nis mother was requirea to leave. CIRCUMSTANCES OF THE DEATH Mr Ogbe-Millar died on 2 December 2021. He was 30 years old and described by his mother as highly intelligent, articulate, charming and well read. For much of his life Mr Ogbe-Millar was a heavy cannabis user, which led to his diagnosis with cannabis induced psychosis in 2020. Mr Ogbe-Millar received treatment from community and in-patient mental health teams at various stages, including two hospital admissions under the Mental Health Act 1983 in late 2020 and in early 2021. On being discharged from hospital in March 2021 he enjoyed a period free of cannabis and psychosis. He was able to work, attend Narcotics Anonymous and come off his medication. This led to his discharge from the community mental health team in June 2021. In November 2021 Mr Ogbe-Millar gave up his job and resumed using cannabis on a daily basis leading to a relapse of his mental illness. His mother sought help from the community mental health team who spoke to Mr Ogbe-Millar by telephone on 26 November 2021 and referred him to a substance abuse organisation, which did not specialise in psychosis. He was discharged by the community health team on 30 November 2021, without the team having obtained any information regarding his relapse from his mother. In the early hours of 2 December 2021, Mr Ogbe-Millar sent a text message to his mother saying: “I’m sorry for my actions and | hope you all find peace”. His mother — — the - who found Mr _ at home The police took Mr Ogbe-Millar to the Emergency Department of Watford General Hospital, which is operated by West Hertfordshire Teaching Hospitals NHS Trust (‘WHTHNT’) where there was an inadequate system for recording the information provided by the police to the hospital concerning his risk of self- harm. Mr Ogbe-Millar was assessed by hospital staff later that morning as a moderate risk of self-harm and told to await the arrival of the local Mental Health Liaison Team, which is operated by the Hertfordshire Partnership University NHS Foundation Trust ((HPUNFT’) Despite Mr Ogbe-Millar’s risk of self-harm and the protective factor provided by the presence of his mother, she was not allowed to stay with him at the Emergency Department while he waited for the Mental Health Liaison Team. Instead, she was required to leave by staff in breach of hospital policy. The Mental Health Liaison Team had not arrived to assess Mr Ogbe-Millar by the time his mother was required to leave the hospital due to problems surrounding the referral system. Soon after his mother had been required to leave, Mr Ogbe-Millar left the Emergency Department unaccompanied saying he was going outside to smoke a cigarette. He never returned and instead travelled to London, where he died after jumping in front of a high speed train at Harrow and Wealdstone train station at 10.09pm on 2 December 2021. Tne MATTERS OF CONCERN are as ronows. — a. Eviaence was heard regarding the appropriate level of observation by Emergency Department staff of mental nealth patients waiting In the Emergency Department (operatea by WHTHNT) to be seen by the Mentar Heaitn Liaison Team (operatea vy HPUNFT). Tnere was confusion amongstthne WHTHNT witnesses as totne appropriate level of observation. Tris was contributed to by a lack of clarity in WHTNHT's (a) Stanaing Operating Procedure entitled: “Management of Mental Health Patients in the Emergency Department (ED) at Watrora Genera Hospitas (WGH): Stanaing Operating Procedure (‘SOP’), Issue date August 2021”; when compared witn (b) WHTNHT’s “Emergency Department Adult Mental Health Pro- forma” Version 3, Undated (‘EDP’); pb. Tne SOP states in a section titiea “5. Procedure” (on page 4 or 169 “Patients at moderate or nignrisk of self-narm or of leaving before assessment and treatment should be observed closely whist in tne ED. Tnere snouid be continuous observation, and this snould be documented in the mental health presentation engagementrecorda (Appenaix 1); c. Whereas the EDP states at page 7 under the heading: “Summary of levels of risk and suggested action’, the following: “Low: No special observations required eaium: Consiaer 15-minute special observation, a. Empnasis nas been aaded above to paragrapns (v) and (c) In Dold text, e. My concern ts tnattne inconsistency between these two documents creates a risk that mental healtn patients at medium risk of self-harm awaiting assessment for their mental health conattion in tne Emergency Department may not be subjected to an appropriate level of observation. ACTION SHOULD BE TAKEN ; a | provided WHTHNT’s solicitors witn an opportunity to supply any Information relevantto the concerns set out inthis report during and after the inquest. My understanding Is that the relevant parts of the policy guidance wnicn have caused me concern remain in place. In my opinion, action snoula now be taken to prevent future deatns, ana | belleve that your organisation nas the power to take such action. YOUR RESPONSE You are unger a duty to respona to tnis report witnin 56 aays of tne date of this report, namety py 2 Aprut 2024. |, tne Coroner, may extend tnis period. Yourresponse must contain detalls of action taken or proposed to be taken, setting out the timetable for action. Otnerwise you must explain why no action Is proposed. COPIES and PUBLICATION | have sent a copy of my report to the solicitors of the Interested Persons in the inquest proceedings: | am also under duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive that response. | may also also send a copy of your response to any other person who | 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 © Mr PA Murphy Area Coroner Northern District of Greater London Dated: 5 February 2024
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.
1 May 2024
North London Coroner’s Service
Barnet, Brent, Enfield, Haringey and Harrow, Barnet Coroner’s Court
29 Wood Street
London
EN5 4BE
Chief Executive’s Office
Watford General Hospital
Willow House
Vicarage Road
Watford
Hertfordshire
WD1 8HB
Dear Mr Murphy
Re: Regulation 28 report to prevent future deaths
I am writing to you in my capacity as Chief Executive of West Hertfordshire Teaching Hospitals NHS
Trust (WHTNH) in response to the concerns you raised following the investigation into the death of Mr
Paz Ogbe-Millar, which prompted your Regulation 28 report dated 5 February 2024.
The concerns brought to our attention include:
a) There was confusion among Emergency Department staff at WHTNH regarding the appropriate
level of observation for mental health patients awaiting assessment by the Mental Health Liaison
Team operated by HPUNFT. This confusion stemmed from inconsistencies between WHTNH's
Standing Operating Procedure titled "Management of Mental Health Patients in the Emergency
Department (ED) at Watford General Hospital (WGH): Standard Operating Procedure (‘SOP’), Issue
date August 2021” and WHTNH’s Emergency Department Adult Mental Health Proforma” Version 3,
which lacked a clear guidance on observation levels.
b) The SOP mentions the need for close observation of patients at moderate or high risk of self-harm,
with continuous documentation, while the EDP suggests only a 15-minute observation for patients at a
medium risk level.
c) Noting the discrepancy, it is evident that mental health patients at medium risk may not be receiving
the appropriate level of observation required for their safety.
We have collaborated with the Royal Free London NHS Foundation Trust to refine our assessment
tools for patients with mental health needs, ensuring accurate identification of the appropriate level of
observation. Consequently, the previously used proforma has been replaced by an electronic
assessment which aligns with the current SOP, eliminating any inconsistencies between the two
documents.
We are committed to enhancing the care provided to patients with mental health needs awaiting
assessment in the Emergency Department. The actions we are undertaking are aimed at improving
patient safety and ensuring that incidents like this do not recur. These include the following:
westhertshospitals.nhs.uk
- The Patient Safety Incident Response Plan (PSIRP) and PSIRF Policy have been approved for
implementation, focusing on key themes including mental health, which will be reflected in our
Quality Account Priorities. (Completed Jan 2024)
-
Implementation of an electronic patient record system to improve access to patient information
and refine assessment tools for mental health patients. (Completed Nov 2021)
- Recruitment of a Matron for Mental Health to elevate the quality of care. (due to be completed
by the end of April 2024).
- Collaboration with Mental Health partnership teams to implement a Suicide Prevention
Pathway Pilot is underway.
- Policy updates and a planned mental health awareness week (May 2024) to set expectations
for staff.
We would once again like to pass on our deepest condolences to Mr Ogbe-Millar's family for their loss.
As a Trust, we have a deep commitment to patient safety and keep our policies and processes under
regular review, The action we have taken reflects our culture of continuous improvement and of
learning in order to further enhance patient care.
Please feel free to get in touch if you require further clarification.
Yours sincerely,
Chief Executive
westhertshospitals.nhs.uk
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