Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0188, written 5 Apr 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 Apr 2024 |
|---|---|
| Reference | 2024-0188 |
| Deceased | Paul Templeton |
| Coroner | Peter Taheri |
| Coroner area | Suffolk |
| Category | Suicide (from 2015) |
| Organisation named | Norfolk and Suffolk 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Trust 1 CORONER , Chief Executive Officer, Norfolk & Suffolk NHS Foundation I am Peter TAHERI, Assistant Coroner for the coroner area of Suffolk 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 24 April 2023 I commenced an investigation into the death of Paul David TEMPLETON aged 65. The investigation concluded at the end of the inquest on 21 February 2024. The conclusion of the inquest was one of: Suicide The medical cause of death was confirmed as: 1a Hypoxic Brain Injury 1b Asphyxiation 1c 4 CIRCUMSTANCES OF THE DEATH The Jury’s answer given in the Record of Inquest to how, when and where the deceased came by his death was as follows: “Paul Templeton came by his death due to the termination of life support on 20th April 2023 at Ipswich Hospital. Paul died at 5:35am. The circumstances leading to Paul's admission to hospital where he eventually died began on the morning of 14th April 2023 at Woodlands, Willow Ward. Between the hours of 8:39am and 9:18am Mr Paul David Templeton cause asphyxiation. Mr Paul Templeton's mental state deteriorated during 2022 to the point at which he was severely malnourished and dehydrated. This led to hospitalisation for kidney injury and later transferral to Woodlands under section 2 of the Mental Health Act. Initial and all subsequent assessments seriously fail to recognise that Paul's prolonged choice not to eat or drink were in fact indications of `action` to end his own life and therefore he should have been considered as a suicide risk.” 5 CORONER’S CONCERNS Regulation 28 – After Inquest Document Template Updated 30/07/2021 During the course of the investigation my inquiries 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: (brief summary of matters of concern) In the words of the Jury: “Initial and all subsequent assessments seriously fail to recognise that Paul’s prolonged choice not to eat or drink were in fact indications of ‘action’ to end his own life and therefore he should have been considered as a suicide risk.” Action is needed to prevent future failure to recognise (a) when the prolonged choice of a patient detained under the Mental Health Act not to eat or drink should be regarded as an action to end their own life; and (b) when such a patient’s prolonged choice not to eat or drink should be recognised as elevating that patient’s suicide risk (including of suicide by means other than malnourishment). At the conclusion of the Inquest, after the Jury had returned the completed Record of Inquest, I asked the Norfolk & Suffolk NHS Foundation Trust (‘NSFT’) to assist me with written information to inform me of what action is being taken to prevent future deaths related to the “serious failures” in risk assessment as to suicide risk identified by the Jury within their answer to how Mr Templeton died. I am grateful for the letter addressed to me, dated 29th February 2024, from the Deputy Chief Executive & Chief People Officer of NSFT. However, the contents of this letter did not allay my concern in this regard. The letter reiterated factual points that were substantially placed before the Jury in evidence. The letter then set out what appears in my view to be the central point that NSFT wished to make: “At no point prior to or during Mr Templeton’s admission, did he present as a risk of self- harm or suicide other than through food or fluid restriction and on that basis there was no evidence to include previous history, recorded thoughts, ideation or plans to identify a risk of ligature. To implement a more restrictive environment upon Mr Templeton without evidence to do so would amount to a blanket restriction in breach of Regulations 13 and 17 of the Health and Social Care Act…” This response does not grasp, engage with, or show reflection in light of the Jury’s finding. It therefore does not allay my concern that circumstances creating a risk of further deaths will occur, or will continue to exist, in the future. The Jury’s finding was precisely that Mr Templeton did present as a risk of self-harm or suicide other than through food or fluid restriction – and that NSFT failed to recognise this risk as it was expressed by way of Mr Templeton choosing not to eat or drink. Although NSFT’s letter argues that implementing a more restrictive environment without evidence to do so would amount to an impermissible blanket restriction, the Jury’s finding was precisely that there was evidence (namely the prolonged choice not to eat and drink) that should have been recognised as being action taken to end his own life and therefore implying an elevated suicide risk. NSFT’s letter goes on to draw my attention to three actions for improvement that are underway or in process. Firstly, “The inpatient clinical team to improve the quality and consistency of their psychological, food and fluid recording and discussions of the same within MDT recording.” While improved discussions regarding food and fluid recording might conceivably trigger recognition of when a refusal to eat or drink indicates suicidal ideation and action, merely recording and discussing food and fluid intake does not necessarily entail recognising when refusal to eat or drink reflects greater suicide risk. This action on its own does not appear to raise awareness among those conducting suicide risk assessments that a prolonged refusal to eat or drink may reflect an elevated suicide risk, as recognised by the Jury. It may be that review is required on the learning, training, and / or guidance given to assist those undertaking suicide risk assessments in relation to how they should interpret a prolonged refusal to eat or drink and the risk of suicide arising from such action. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Of course, it is not for the Coroner to recommend what action is required or to make specific remedial recommendations. Secondly, “The Community and Crisis team were identified as requiring improvement by ensuring routine weighing of patients to provide baseline and discussing and sharing the same…”. Thirdly, “The Crisis team was identified as requiring improvement in respect of ensuring physical health is monitored and considered within assessments…” Neither of these actions address the particular concern highlighted by the Jury’s finding, not least as the serious failures identified by the Jury took place in Woodlands and not in the Community or Crisis teams. 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 May 31, 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 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 Dated: 05/04/2024 Peter TAHERI Assistant Coroner for Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Assistant coroner Peter Taheri Suffolk Coroner’s Court Beacon House Whitehouse Road Ipswich IP1 5PB NSFT Trust Management Norfolk & Suffolk Foundation Trust County Hall Martineau Lane Norwich NR1 2DBH Date: 31 May 2024 Dear Mr Taheri Regulations 28 and 29 (coroners investigations regulations 2013) notification made in response to the death of Mr Paul Templeton I write to you in respect of Mr Templeton who died on 20th April 2023. His inquest concluded on 21st February 2024. At the end of the inquest, you raised concerns outlined in this response within a prevention of future deaths notification. I would like to reiterate to you and to Mr Templeton’s family our sincere regret and apologies for the death of Mr Templeton whilst under our care. You identified that action is needed to prevent future failure to recognise: (a) when the prolonged choice of a patient detained under the Mental Health Act not to eat or drink should be regarded as an action to end their own life; (b) when such a patient’s prolonged choice not to eat or drink should be recognised as elevating that patient’s suicide risk (including of suicide by means other than malnourishment). In response to your concerns (a) & (b) we have acted to secure assurance that assessors working within Willows ward have the skills and awareness required to undertake comprehensive holistic risk assessments, including an understanding and awareness of the significance of food and drink in mental health risk assessment. A reflective Multi-Disciplinary Team (MDT) Away Day was held on 15th and 17th May 2024. During this, the team explored the application of clinical risk assessment skills to a range of different cases. This was undertaken to support the transition of knowledge into clinical practice and provide assurance of consistency between staff members. The case studies included scenarios related to food and drink to raise staff awareness. To maintain a good standard of clinical practice this will be discussed in clinical supervision and reviewed within future team meetings. To ensure focus on appropriate clinical risk assessment, the Team are using Daily Team huddles to prompt assessors to consider holistic care / including eating and drinking within their clinical risk assessments. To support this, we have also made changes to the SBAR (Situation Background Assessment recommendation) record that the team use to communicate and share patient information at handover. The revised SBAR provides more information about eating and drinking (identifying quantity not just appetite) to inform clinical risk assessment. - 2 - The Trust focus on clinical risk assessment is further supported through current updating of the Trust Clinical Risk Assessment and Management Policy. This Policy is progressing through Trust internal governance processes and is due to be published end of June 2024. This will provide additional support to staff clinical risk assessment practice. We will secure assurance regarding clinical risk assessment through audit. The audit findings will report to the Care Group Quality Assurance Group for monitoring purposes and to support further improvement. For further assurance the report will be presented to the Trust Safety group and onward to the Trust Quality Committee. We have also reviewed the training we offer to staff to support their assessment of clinical risk. The current clinical risk training offer is inclusive of mandatory suicide awareness training, Ligature training, Oliver McGowan Autism Training, Safeguarding level 3 trainings, and physical healthcare training. This includes the national NHS England approved suicide prevention (eLearning) package. The challenge for the Trust is to secure a training package which sufficiently addresses both clinical risk assessment and food and nutrition. The national approved training, required as mandatory by the Trust, does not reference suicide through malnourishment. The Trust’s 3P (Presenting, predisposing, precipitating, perpetuating & protective factor training) programme highlights the importance of good nourishment but does not link this to suicide. We recognise that to deliver content linking suicide prevention training with content referencing malnourishment we will need to develop and deliver a bespoke package of training supported by subject matter experts. We are in the process of discussing this with our Physical Health team and raising this with NHS England and the Royal College of Psychiatrists for their broader consideration. From a Trust perspective, senior meetings have been held between the Trust’s Education Department, Chief Nursing Officer and Directors, to review and refresh the NSFT Education Strategy, inclusive of reviewing / extending training offers which focus on clinical risk assessment. The outcome of this work is scheduled to report in June 2024. The tragic death of Mr Templeton has identified a number of key learning points for the Trust. As described above, a number of actions have been undertaken that address your concerns. Yours sincerely Chief Executive Officer
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