Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0104, written 22 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 | 22 Dec 2023 |
|---|---|
| Reference | 2024-0104 |
| Deceased | Larry Spriggs |
| Coroner | Darren Stewart |
| Coroner area | Surrey |
| Category | Mental Health related deaths |
| Organisation named | Surrey and Borders 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive Officer Surrey and Borders Partnership NHS Foundation Trust 1 CORONER I am Darren Stewart OBE, Assistant Coroner, for the Coroner Area of Surrey 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 10th June 2021 I commenced an investigation into the death of Larry Stephen SPRIGGS. The investigation concluded at the end of the inquest on 7th December 2022. The inquest was heard without a Jury. Mr. SPRIGGS died of: 1a. Multiple Injuries The jury returned the following narrative conclusion: Frimley Park (23rd May - 25th May) Mr Spriggs was admitted to Frimley Park hospital on the 23 rd May 2021 after attempting to commit suicide by overdosing was assessed as suffering a mental health crisis and placed into a highrisk category. He was kept at Frimley Park Hospital until he was transferred to Farnham Road Hospital. . He Farnham Road (25th May - 27th May) Upon admission to Victoria ward at Farnham Road on the 25th May 2021 at 6:45pm, Mr Spriggs's risk was assessed as low, compared to the assessment of his risk at Frimley Park hospital as high. Upon clerking-in he presented as calm, regretful and rational, presenting as low risk to self with no suicidal ideation at the time. The reduction from a previously assessed level of high risk to low risk made a possible contribution to his death as this may have impacted the urgency of the risk management plan. The assessment did however recommend that 1-1 observations should continue. During the first night of his stay in Farnham Road Hospital, Mr Spriggs attempted to self-discharge in the early hours of the morning due to high dissatisfaction of the room, isolation and observation regime. Mr Spriggs was persuaded to remain on the ward by staff. 1 The consultant psychiatrist on the ward made a preliminary diagnosis for Mr Spriggs of an acute stress reaction, he noted that Mr Spriggs displayed no symptoms to have reached the threshold for pathological mental illness. The consultant psychiatrist did note that Mr Spriggs displayed fluctuating levels of anxiety from the collateral history. The consultant psychiatrist prescribed no anti- anxiety medication at this time and the failure to do so possibly contributed to Mr Spriggs death. Mr Spriggs was offered anti-hypertension medication following high blood pressure readings on the 26th May 2021 but turned it down. On the 27th May 2021 he decided to proceed with taking this medication when offered again. The decision to reduce Mr Spriggs observations from 1-1 to intermittent was made on the 26th May 2021 following assessment. The reduction in observations to intermittent made a material contribution to Mr Spriggs death. Mr Spriggs was not expecting the environment he was placed into (both the setup of his room and the isolation period which was policy at the time for Covid-19) this led to a higher state of anxiety, reflected in the distressed texts sent to his partner. His partner received additional distressed texts from Mr Spriggs on the 26th May 2021, stating "get me out of here" and "it feels like a prison" and "there is something in my tea" Following a conversation between a member of staff and Mr Spriggs partner, the details of these texts were recorded on Mr Spriggs records. Staff on the following shift failed to make themselves aware of this important information. This failure made a material contribution to Mr Spriggs death 27th May On the morning of the 27 th May 2021, during a review of his blood test results Mr Spriggs was offered anti-hypertensive medication, vitamin D tablets and sleeping medication, which he was then willing to take. Mr Spriggs had reported to the doctor that his room and the isolation was causing him a lack of sleep and that he was not feeling very well. On the morning of the 27th May 2021— Mr Spriggs was in communication with his partner still telling her that he wanted to leave but that he had to call her back as staff members had entered his room for observations. At 9:48pm on the 27th May 2021, Mr Spriggs was given his medication that had been offered earlier in the day. At approximately 9:52pm on the 27th May 2021, the CCTV picks up the last movement from inside Mr Spriggs room. Between 9:54pm -9:57pm on the 27th May 2021, Mr Spriggs exited the window and fell to the ground which was recorded on CCTV. Observations on the night of the 27th May 2021 2 On the evening of Mr Spriggs death, the observations that were carried out on Mr Spriggs were inadequate. There were inconsistencies in the quality of observations, the observation sheet was pre-populated with observation timings, the timing of observations were not random, inaccurate engagement codes were entered onto the observation sheet and conversations with Mr Spriggs did not take place, these failures made a material contribution to Mr Spriggs death. Following from these inadequate observations, the handover to the next HCA did not take place verbally and the inaccurate observation sheet was left in the lounge on the ward, instead of in the nurses station. Induction training for staff on the evening of 27th May 2021 was inadequate and failed to explain what an observation should include and how they were to be carried out. The second sheet of the formal induction checklist document for the evening of the 27th May 2021 was not signed by the inductor. The effect of these failures meant that arrangements to manage the observation regime were inadequate and made a material contribution to Mr Spriggs death. The death was contributed to by Neglect. The death was caused or more than minimally contributed to by the failure on the part of Surrey and Borders Partnership NHS Foundation Trust to ensure the adequate implementation of intermittent observations in relation to Mr Spriggs's care. Larry Stephen Spriggs died as a result of misadventure. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are recorded in the Jury’s Narrative Conclusion. 3 5. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. The MATTERS OF CONCERN are as follows: a. The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk. b. Use (or non-use) of anti-anxiety medication in relation to the support of Mr. SPRIGGS' symptoms. c. Passage of information between staff concerning patients care and treatment. d. The adequacy of arrangements to manage and implement the intermittent observation regime at Farnham Road Hospital. e. Processes for the management of incidents at Farnham Road Hospital such as those on the 27th May 2021 when Mr. SPRIGGS fell from the window of his room. I received further evidence orally and in writing from the Interested Persons’ subsequent to the completion of the Inquest in relation to these concerns. This evidence included a response from Surrey and Borders Partnership NHS Foundation Trust (SABP). The Trust outlined a number of prospective measures it is either considering the implementation of, or has plans for their implementation. These measures included: 1. The Trust was reviewing its risk assessment policy, including a new risk assessment tool. 2. Training and induction packages have been reviewed and revised for staff, including junior doctors and temporary ward staff. 3. A draft Care Planning Principles Policy has been developed. 4. The 10 Key Steps to Safety handover document used by the Trust has been reviewed and revised. 5. The Observation Competency Checklist has been changed following review. 6. The Trust is implementing the Systems Engineering Initiative for Patient Safety (SEIPS). It was explained to the court that these measures should be seen in the context of wider cultural change management being undertaken by the Trust at Farnham Road Hospital. 4 I have taken account of the measures, many of which are prospective, as outlined by SABP. However, I remain concerned in relation to the matters identified at sub-paragraphs a to d (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 of the cultural change in the delivery of care and treatment of patients, accepted by the Trust as required, was not provided to the court; either in the form of a plan to bring such change about, or evidence that such change has otherwise occurred. The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk, including the prescription of anti-anxiety medication. Passage of information between staff concerning patients care and treatment. The adequacy of arrangements to manage and implement intermittent observation at Farnham Road Hospital. 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 16th 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: a. Family of Larry Stephen SPRIGGS b. Surrey and Borders Partnership NHS Foundation Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. 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 5 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 22nd December 2023 Darren Stewart OBE 6
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.
16 February 2024 Private and Confidential Mr Darren Stewart OBE Assistant Coroner for Surrey 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 Larry Spriggs (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 22 December 2023, in relation to the inquest touching the death of Larry Spriggs. 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. We have reflected on the concerns set out within your PFD Report and have outlined below the steps that have been taken and are being taken to address these. Evidence of the cultural change in the delivery of care and treatment of patients In 2023, the Trust launched a new five year strategy to meet the needs of the people we serve across Surrey and North East Hampshire. This strategy focuses on delivering high quality care and placing people who use services at the centre of everything we do. We have identified a number of strategic ambitions which includes strengthening involvement with people, carers and families and being a learning organisation. In relation to inpatient wards, the Trust has embarked upon an Inpatient Improvement Plan which has the overarching aim of developing our inpatient care through safety and quality improvements to ensure better outcomes for those using our services. This is reported through the Inpatient Improvement Board and encompasses clinical, workforce, infrastructure, digital and environmental change. There has also been a review of our operational model for inpatient services. As of 1 September 2023, all of the Trust’s inpatient services have been managed under one Hospitals Division with shared quality and operational management structures allowing cultural change to be delivered through compassionate, inclusive leadership. Page 1 of 4 In addition, the Trust has now adopted the Patient Safety Incident Response Framework (PSIRF) which is part of the approach to patient safety that is described within the National Patient Safety Strategy. PSIRF will enhance our safety and learning culture by creating much stronger links between patient safety incidents and learning, working in collaboration with those affected by the incident. In turn, this fosters a culture of transparency and openness amongst staff in reporting incidents and engagement in implementing improvement to embed learning. The improved safety culture within the organisation is demonstrated in the results of our staff survey. Our overall staff engagement scores across the Mental Health & Learning Disability and Mental Health, Learning Disability & Community sector showed that we were within the top three Trusts within this sector. In particular, 92.3% of staff reported that our organisation encouraged them to report errors, near misses or incidents, and 82.4% of our staff feel secure raising concerns about unsafe clinical practice. This tells us that staff involved in an error, near miss or incident feel they are treated fairly and that there is confidence that our Trust will take action to ensure that these do not happen again. As part of our ambitious plan to continue to improve culture within the organisation, the Trust has also registered for the NHS England Culture of Care Programme. This aims for wards to provide safe, therapeutic and equality focused care in accordance with co-produced Culture of Care Standards for Mental Health Inpatient Care. This programme includes Quality Improvement coaching for up to four inpatient wards which will receive close support to implement change theory by testing several changes over the two year programme. In addition, it provides leadership coaching as well as to support to move towards a holistic approach to safety. There have been a number of initiatives specifically relating to culture change on Victoria Ward. Since early 2023, the Matrons and Ward Managers from the older adult wards have been participating in an Action Learning Set which is an opportunity to reflect on issues on the wards and provide group counselling to identify solutions. This is being facilitated by an Organisational Development consultant on a two monthly basis, who also attended an away day for qualified staff working on Victoria Ward in December 2023. This focused on team working and a number of changes for implementation were discussed and agreed. From 2024, there have been separate monthly meetings for Health Care Assistants and for qualified staff in addition to the overall staff meeting. The purpose of these meetings is to address development needs specific to that staff cohort and are predominantly teaching sessions. It is intended that these sessions will greatly enhance staff knowledge and skills while increasing staff feelings of belonging and a desire to continually improve the care and treatment for people on our inpatient wards. In addition, we receive insights into our culture via the Your Views Matter survey results, which asks people to share their experiences with our services. From August 2023 to February 2024, we received 81 responses in relation to our inpatient services for older adults. Of these, 73 people rated their overall experience as “very good” or “good” and 76 responded that the care and services they needed were organised “very well” or “well”. We recognise that there is still work to be done around cultural change to support the care and treatment of people using services and their families and carers. As part of this, we have recently commissioned an external review of quality control processes and are currently working on our implementation plan. The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk, including the prescription of anti-anxiety medication. Further to NICE guidelines indicating a change from the global stratification of risk into “low, medium or high”, the Trust developed and successfully piloted a new Risk Assessment Template which went live in January 2024. This, together with the mandatory suicide prevention training for clinicians which was introduced in November 2022, has improved our ability to assess inpatient risk. Page 2 of 4 The Risk Assessment Template allows clinicians to formulate risk presentation taking into account a range of factors and identify the most appropriate way to manage risk. This includes whether medication should be prescribed. Clinical decision making is made on a case by case basis and must also consider NICE guidelines which outline a preference for therapeutic intervention over the prescription of medication. Such decisions are often finely balanced, particularly where there are additional risks, for example, in prescribing benzodiazepines in older adults. Passage of information between staff concerning patients care and treatment. Measures have been introduced to improve the passage of information between staff across our inpatient wards. It is acknowledged that embedding change takes time and we are committed to continually improving our processes to ensure effective and timely communication of information. At the twice daily handover between staff, key documents including the 10 Keys Steps to Safety and the SBAR (Situation, Background, Assessment, Recommendation) are reviewed. The SBAR is updated electronically twice per day by the nurse in charge prior to handover. Additionally, there is a daily handover between the nurse in charge and the junior doctors on the ward. Where any member of staff receives information which suggests that risk should be reviewed urgently, including concerns raised by family or carers, that information should be handed over to the nurse in charge. Information that is handed over verbally should then be added to the SBAR and the nurse in charge will consider the need for review of the risk assessment or therapeutic measures such as an increase in the level of observation. This can be implemented immediately and does not require waiting until handover. A Daily Safety Report is also completed by inpatient wards and discussed at the daily safety call meetings attended by senior leadership from all wards. On each night shift, a Hospital Duty Manager (who is a senior nurse) is identified to complete a Daily Handover Report for the morning staff. This includes details of staffing levels, incidents on the ward and actions taken to maintain safety. The Daily Handover Report is shared with all senior staff on the day shift, including the senior matrons and associate director. Furthermore, on call junior doctors also produce a written handover report detailing any safety issues, health monitoring or additional tasks to be completed by the day team. This range of measures ensure that safety critical information is passed between staff in a timely manner. The adequacy of arrangements to manage and implement intermittent observation at Farnham Road Hospital. Observation competency checklists are completed at staff induction for all substantive and temporary staff working on Victoria Ward. An observation prompt sheet is provided to staff completing observations. The responsibility for overseeing observations lies with the nurse in charge. From June 2023, Victoria Ward introduced the Supportive Observations Audit Tool. This provides a quality assurance process for not only the policy compliance around supportive observations, but also in the wider context of MDT overview, clinical rationale, care planning and the views of the person. Audits of ten people in the care of the Victoria Ward are carried out on a monthly basis. In addition, and in co-production with the Victoria Ward clinical team and the Quality Improvement team, a digital solution has been developed for the recording of supportive observations and therapeutic engagement. It is intended that this will be tested and evaluated for its impact on safety prior to a decision about wider roll out across the organisation as part of the current Inpatient Improvement Plan. Page 3 of 4 There is a national observation improvement programme underway and the Trust is leading one of the work streams around workforce and training. The programme is led by the National Mental Health and Learning Disability Nurses Directors Forum who are reviewing therapeutic observations and engagement practice. The Trust is part of the Project Board and will be implementing recommendations from the review alongside other mental health trusts. On behalf of the Trust, I would like to offer our sincere condolences to Mr Spriggs’ family for their loss. We hope that our actions outlined above assures you and Mr Spriggs’ family that we have reflected on your concerns and provided reassurance as to our processes. Yours sincerely, Chief Executive Page 4 of 4
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