Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0174, written 7 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Mar 2024 |
|---|---|
| Reference | 2024-0174 |
| Deceased | David Siirak |
| Coroner | Richard Furniss |
| Coroner area | West London |
| Category | Other related deaths |
| Organisation named | Central and North West London 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.
West London Coroner Service 25 Bagleys Lane, Fulham, London, SW6 2QA Date: 7 March 2024 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Director of Safety Central and North West London NHS Foundation Trust 350 Euston Road Regent's Place London NW1 3AX CORONER 1 2 I am Richard Furniss, Assistant Coroner at West London 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 INQUEST 3 I conducted an Inquest into the death of David Louis SIIRAK between 4 and 7 March 2024. Mr Siirak was a detained inpatient in Frays Ward in the Riverside Centre. On 1 March 2020, he was the victim of a serious assault at the hands of another patient in his room on the Ward, as a result of which he suffered unsurvivable injuries which caused his death on 4 March 2020. 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. 5 The MATTERS OF CONCERN are as follows. Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020. The crash team, led by , arrived at 1703 hours. The evidence was that between those times (until charge at 1703) the response of ward staff to the incident was "chaotic" and "panicking" (as was acknowledged by the staff). took The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By "simulated emergency", I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day. One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since. The jury found that "there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020." It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you, Mr Pooler, 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 Monday 6 May 2024. I as coroner may extend the period. 7 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (father of the Deceased) and (sister of the Deceased) by their solicitors Messrs Hodge Jones & Allen. 8 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. 8 March 2024 9 Signature Richard Furniss, Assistant Coroner for West London
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.
Executive Office 7 May 2024 Richard Furniss, Assistant Coroner at West London West London Coroner Service 25 Bagleys Lane, Fulham, London, SW6 2QA Dear Assistant Coroner Furniss, Regulation 28: Report to prevent future deaths in relation to David Siirak I am responding to the Regulation 28 Report issued on 7 March 2024 following the inquest into the death of Mr David Siirak on 4 March 2020. The inquest concluded on 7 March 2024. Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of Mr. Siirak and the distress this has caused his family. We accept the findings of the jury and have evaluated our response to the tragic death of Mr Siirak in light of the findings. Matter of Concern Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on , arrived at 1703 hours. 1 March 2020. The crash team, led by took charge at The evidence was that between those times (until 1703) the response of ward staff to the incident was "chaotic" and "panicking" (as was acknowledged by the staff). The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By "simulated emergency", I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day. One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since. The jury found that "there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020." Trust Headquarters, 350 Euston Road, London NW1 3AX Telephone: 020 3214 5700 www.cnwl.nhs.uk It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training. I have addressed the concerns below : Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises. All Staff who were present during this incident, who still work at the trust, have now successfully passed and had experience of Resuscitation simulation. Training for temporary staff who work at CNWL is provided in line with an agreed training matrix as set out by Skills for Health. This standard means that all temporary staff who work within the Trust meet the agreed training standards for resuscitation. Insitu simulation: This has been developed alongside a Trust-wide insitu Simulation education programme and compliments the training programme outlined above. This programme was launched and led by the head of Adult Education at CNWL in 2022. The Trust-wide programme covers many areas, with resuscitation simulation being one of those areas. This uses a unified approach to planning, running, debriefing and recording each simulation. The Resuscitation team has a suite of simulation’s developed from previous incident that have occurred across the trust. Everyone involved in delivering and facilitating simulation has attended training provided by Milton Keynes University in 2022 and 2023, and local update training is planned for 2024. Since the launch of the programme over 100 insitu resuscitation simulations have been carried out across the trust, with 79 having occurred in the last year, one of these has occurred on Frays ward, including five members of staff. As Frays ward sits on the Hillingdon Hospital site, and is covered by the Hillingdon Hospital Resuscitation team, they also provide insitu simulation and as a result an additional insitu simulation session has taken place. The date and content of the insitu simulation is discussed with the Ward Manager or Matron, areas and type of resuscitation is discussed together with a date to occur e.g. ligature, choking etc. Staff to attend is determined locally by the Ward Manager and Matron. The simulation is then run either as an unannounced or planned exercise. The team runs equal number of both. Ward Managers and Matrons share learning from local insitu simulations with the wider team via team meetings and share additional learning across the local service via their Local Care Quality Group meetings. Reports on simulations run, together with lessons learnt and follow on actions are also presented twice yearly to the Resuscitation and Deteriorating Patient Committee chaired by the Deputy Chief Medical Officer of the Trust. Over the next 12 months, a rolling programme of insitu simulations is scheduled for every inpatient ward area, with additional sessions planned for areas identifying a greater need. Areas which may be considered as requiring additional input will include teams that have been involved in a recent resuscitation event and incident reviews. The Trust is also currently building a simulation room, where staff identified as having a need to refresh can attend for planned sessions. Thank you for raising your concerns. I hope that the content of this letter provides sufficient assurance that CNWL take the concerns raised seriously, has taken action following the death of Mr Siirak and has accepted the points raised and continues to work to improve the service we provide. Should you have any questions or concerns or comments, please do not hesitate to contact me directly. Yours sincerely, Chief Nursing Officer and Deputy Chief Executive
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