Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0234, written 1 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2024 |
|---|---|
| Reference | 2024-0234 |
| Deceased | Harry Hall |
| Coroner | Andrew Hetherington |
| Coroner area | Northumberland |
| Category | Mental Health related deaths |
| Organisation named | Cumbria, Northumberland, Tyne and Wear 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.
ANDREW HETHERINGTON
HM Senior Coroner for Northumberland
County Hall Morpeth Northumberland NE61 2EF
Date: 1 May 2024
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Cumbria, Northumberland, Tyne and Wear NHS
Foundation Trust
CORONER
I am Mr Andrew Hetherington for Northumberland
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.
1
2
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 1 June 2023 I commenced an investigation into the death of Harry David HALL. The investigation
concluded at the end of the inquest on 30 April 2024. The conclusion of the inquest was Suicide
1a Intracranial Bleed
3
1b
1c
II
CIRCUMSTANCES OF THE DEATH
Harry David Hall had a history of depression, mental health illness and had expressed recent suicidal
ideation. In the period leading up to his death he had been researching various websites relating to
suicide.
4
He was under the care of the West Northumberland Community Treatment Team and no in person
assessment had taken place prior to his death.
At approximately 16.30 hours on 29 May 2023 in the rear garden of Croydon Cottage Thorngrafton
Hexham Northumberland he was found with a self-inflicted traumatic head injury the result of the
firing of a captive bolt gun that he had recently purchased
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.
The MATTERS OF CONCERN are as follows. -
[BRIEF SUMMARY OF MATTERS OF CONCERN]
5
(1) The deceased was seen by his General Practitioner on 27 March 2023 when he described ongoing
suicidal ideation. His General Practitioner referred him to the 24-hour crisis team at 17.56 hours on 27
March 2023. The Initial Response Team ("IRT") provides 24 hour access to urgent mental health care
and treatment. The IRT called the deceased at 22.37hrs on 27 March 2023 and I am told during which
no immediate risks of self-harm were identified and although frequent thoughts of suicide were being
experienced they were felt to be chronic in nature. The clinical decision was to not to refer on the
Crisis Team and instead refer to the West Northumberland Community Treatment Team. There were
two letters the first dated 31 March 2023 offering an appointment on 17 May 2023 and the second
dated 4 April offering an appointment on 26 June 2023. I heard there was a ten week delay in
appointments although that delay has since been rectified. The appointment on 17 May 2023 did not go
ahead. No evidence was given as to why the appointment on the 17 May 2023 did not go ahead. There
is nothing in the records, it is unclear if any assessment was undertaken at that time and this is crucial
information. It is speculation if the outcome would have been any different if the deceased had been
seen prior to his death. I am concerned with regard to the record keeping at this time.
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths and I believe you Cumbria,
Northumberland, Tyne and Wear NHS Foundation Trust 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
25 June 2024. I, the 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: Mr
Hall's family
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.
1 May 2024
9
Signature
Andrew Hetherington HM Senior Coroner for Northumberland for
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.
St Nicholas Hospital Jubilee Road Gosforth Newcastle upon Tyne NE3 3XT Andrew Hetherington HM Senior Coroner for Northumberland Dear Sir Inquest into the death of Harry David Hall Regulation 28 Report to Prevent Future Deaths Response We write in response to your Regulation 28 Report dated 1 May 2024 following your investigation into the death of Harry David Hall. Cumbria Northumberland Tyne and Wear NHS Foundation Trust would like to express our deepest condolences to the family of Mr Harry David Hall. The Trust takes all patient deaths very seriously and investigates them very thoroughly to establish if lessons can be learned or services can be improved. Your concern was as follows: 'No evidence was given as to why the appointment on the 17 May 2023 did not go ahead. There is nothing in the records, it is unclear if any assessment was undertaken at that time and this is crucial information. It is speculation if the outcome would have been any different if the deceased had been seen prior to his death. I am concerned with regard to the record keeping at this time.' The Trust has since carried out a thorough investigation of Mr Hall's electronic healthcare records and established that the appointment dated Wednesday 17 May 2023 was created in error by an administrator, who has since left the organisation. At the time that the appointment was created, the administrator also created an appointment letter however the appointment letter was not sent out. A note was added to the Client Diary section of Mr Hall's electronic healthcare record confirming this. The image below shows the client diary section of the electronic healthcare record and highlights the date and time the May 17th appointment was initially entered by the admin staff member, and then the time it was cancelled. In the details column it is clearly noted that the appointment was cancelled as it had been entered in error. This image below shows that a document (appointment letter) was added on 31 March 2023 at 09:35. The Document Description states that the letter has not gone out – appointment cancelled. There was therefore no cancelled appointment and therefore no omission of rationale for the perceived cancellation. Furthermore, as was explained in the hearing, Mr Hall would have been seen within the 18 week timeframe that was the appropriate benchmark at the time. Unfortunately, the location of the note was not clear to the two staff witnesses who attended Mr Hall's inquest to provide evidence. The staff members wrongly assumed that the reason why the appointment was cancelled should have been documented in the progress notes therefore they did not explore the Client Diary feature on the record which expanded to show the patients appointment details and appointment history. The Trust is confident that there was never an appointment planned for 17 May 2023 and Mr Hall was only ever provided with and made aware of the appointment dated 26 June 2023. At the point of Mr Hall's referral in March 2023, the Trust benchmarked on having no patients waiting over 18 weeks for assessment (this was the Trust's quality priority at the time). At that time, West Northumberland Community Treatment Team faced significant challenges regarding staffing resources. The challenges have now been resolved and the wait to assessment times have significantly reduced to under the new 4-week performance indicator, as stated in evidence during the hearing. In circumstances when scheduled appointments are cancelled for a genuine reason the Trust expectation for documentation of that reason is as follows: Staff Member Cancellation: If a staff member cancels an appointment, the Admin Team contact the patient to inform them. Patients are contacted by phone if the cancellation is last minute, and patients are texted if they cannot be reached by phone. The appointment is then cancelled in the patient's electronic healthcare record diary and the reason for the cancellation is documented i.e. cancelled by clinician. A note is also added to If the appointment is the patient's progress notes section on the electronic healthcare record. rescheduled, an appointment letter is generated, sent to the patient and uploaded into the documents section of the electronic healthcare record. Patient Cancellation: If a patient contacts the service to cancel their appointment, the appointment is cancelled in the patient's electronic healthcare record diary and the reason for cancellation is documented i.e. cancelled by patient. A note is also added to the patient's progress notes section on the electronic healthcare record. If the appointment is rescheduled, an appointment letter is generated, sent to the patient and uploaded into the documents section of the electronic healthcare record. Appointment Created in Error: If an appointment is created in error by a staff member, the appointment is cancelled in the patient's electronic healthcare record diary and the reason for cancellation is documented i.e. created in error. We hope that the above demonstrates that the Trust has invested time, effort and resource into investigating the issue you highlighted with a view to improving patient care and safety and reducing the risk of any adverse incidents or outcome in the future. We often find it helpful to engage with Coroners in the local area to discuss any issues or concerns and would welcome a further conversation with you regarding this matter, should you find it useful to do so. Yours faithfully Medical Director / Deputy Chief Executive
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