Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2024-0091, written 17 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Mar 2017 |
|---|---|
| Reference | 2024-0091 |
| Deceased | Trevor Curry |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Sussex Partnership 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.
VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC __ GILVA D.J.TISSHAW, BA(LAW)HONS THE CORONER'S OFFICE WOODY ALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 29204 7 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. , Chief Executive, Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing. BN13 3EP CORONER I am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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. INVESTIGATION and INQUEST On 1yth June 2016 I commenced an investigation into the death of Trevor John CURRY. The investigation concluded at the end of the inquest on 1yth March 2017 .The conclusion of the inquest was a Narrative Conclusion - see attached sheet. CIRCUMSTANCES OF THE DEATH See Record of Inquest 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. 1 2 3 4 5 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC __ GILVA D.J.TISSHAW, BA(LAW)HONS THE CORONER'S OFFICE WOODY ALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 The MATTERS OF CONCERN are as follows. - (1) It is nationally acknowledged that there are a growing number of patients in both acute and psychiatric hospitals and prisoners who have substantial mental health and physical problems. This is particularly the case in view of the ageing hospital and prison population. It is therefore incumbent upon those caring for such people to ensure that they have full mental and physical past medical histories. In this particular case at Inquest, I accepted that the deceased's sister had informed the triaging and admitting staff atthe psychiatric hospital of the fact that he was being seen by the Cardiologist and was suffering with heart problems (i.e. palpitations). No note was made of this in Mr Curry's admitting note. It should have been. In addition, the psychiatric trust made no effort to ascertain his full past physical history until after he had died. Of course they were not expecting him to die within 48 hours of admission but that is not the point. Enquiries of this nature should be made at the earliest opportunity and if there are no reciprocal IT arrangements then the individual trusts must have arrangements between them so that they can access appropriate history speedily. This is particularly important in cases where a patient is admitted to a psychiatric hospital in an agitated, even psychotic state and unable to give an appropriate history him or herself. 6 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by gm June 2017. 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. 2 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPl,FRL _ GILVA D.J .TISSHA W, BA(LA W)HONS 8 COPIES and PUBLICATION THE CORONER'S OFFICE WOODY ALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 29204 7 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. 2. Foundation Trust , Head of Legal Services, Sussex Partnership NHS 3. Secretary of State for Health, Department of Health 4. 5. 6. - Chief Executive NHS England - Sussex Partnership Trust - Millview Hospital 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: 17tn March 2017 SIGNED BY: 1/,ir_~!fKv~(1 Senior Coroner Brighton and 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.
A member of: Association of UK University Hospitals IE(CfE ~VfE [)j 12 t~1:ki Sussex Partnership NHS Foundation Trust 1 June 2017 Miss Veronica Hamilton-Deeley LLB Her Majesty's Senior Coroner for the City of Brighton & Hove The Coroner's Office Woodvale Lewes Road Brighton BN2 3QB Trust HQ Swandean Arundel Road Worthing West Sussex BN13 3EP Dear Miss Hamilton-Deeley Re: The late Mr Trevor John Curry Thank you for your letter of 20 March 2017, enclosing your report written under Paragraph 7, Schedule 5 of The Coroners & Justice Act 2009 and Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013, a copy of the text of the whole rule and the Record of Inquest. Firstly, may I offer my sincere condolences to Mr Curry's family on their tragic loss. This letter is intended to set out the learning and actions we have taken at Sussex Partnership NHS Foundation Trust following Mr Curry's death and I hope it provides you and Mr Curry's family with assurance that we have taken the lessons you have highlighted extremely seriously. I am sorry the information from Mr Curry's sister that Mr Curry was being seen by a cardiologist and he was suffering with palpitations was not recorded in the health records. , General Manager -Acute and Urgent Care Services for Brighton and Hove drafted a briefing for staff highlighting your concerns to ensure the lessons are widespread throughout the Trust. The briefing and ongoing team meetings and clinical supervision sessions have been used highlight the importance of good clear documentation in our new electronic health records system. This has assisted our learning and an improvement in our recording. Senior members of staff such as Ward Managers and Matrons at Mill View the expected standards of Hospital complete documentation audits documentation are met. to ensure In relation to the timely requests for primary care records and information about our patients, I am pleased to say a new system has been introduced. The new system, now in use is as follows; The Crisis Resolution and Home Treatment Team administrators request a copy of the primary care, summary care record, or encounter report, from the GP Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP www.sussexpartnership.nhs.uk A teaching trust of Brighton and Sussex Medical School practice for all new patients admitted to Mill View hospital. This is done within 48 hours of admission and the administrators verify all new patient admissions at the daily Acute Referral Meeting (ARM) which is attended by the Bed Manager. The Crisis Resolution and Home Treatment Team administrators upload the primary care, summary care record / encounter report to the Trust's electronic health records system 'Carenotes' which all clinical staff in the Trust have access to. Laminated copies of the guidance has been circulated to the wards at Mill View Hospital and it is displayed for staff as a reminder and for easy reference. Please find enclosed our new Protocol for the Management of Primary Care Clinical Information for all Patients admitted to acute inpatient services for your information. (Chief Pharmacist) produced guidance for staff regarding the In addition, importance of obtaining the primary care, summary care record, which was distributed to Trust staff and taken to staff meetings for sharing and discussion. Clinicians in both primary and secondary care can access summary care records using an NHS Smartcard, once they are set up on the national system. Furthermore, the Trust is currently looking to establish an "opt out" system so that patients in contact with our services are informed that summary care record access will occur by default unless they specify that it may not, (unless a best interest decision needs to be made). confirmed that this guidance is now included in the induction pack for all new junior doctors joining the Trust. (Chief Pharmacist) has The learning from Mr Curry's death has been included in the Trust's quarterly quality report available to all Trust staff and our Clinical Commissioning Groups. I note your conclusion confirmed that Mr Curry's treatment and medications during the course of his admission were appropriate and made no contribution to his sudden death. Nonetheless, we take each and every death very seriously. As a result of the lessons from your inquest, and as a legacy to Mr Curry, we have learnt from this, and I hope you feel reassured that we have introduced an achievable and improved system for the acute wards to obtain such important information to assist us with the care of our patients. We are committed to continually learning, improving and strengthening relationships with our primary care colleagues for the benefit of our patients and their families and carers. Yours sincerely Chief Executive Encs. Cc. (Non Executive Director) 2
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