Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0324, written 13 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jun 2024 |
|---|---|
| Reference | 2024-0324 |
| Deceased | Harry Vass |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Bristol NHS 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.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 13 June 2024 REF: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Royal College of Nursing 20 Cavendish Square London W1G 0RN CORONER I am M. E. Voisin HM Senior Coroner for Avon 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 1 2 3 INVESTIGATION and INQUEST On 17/1/23 an investigation was commenced into the death of Harry Roland Ian Vass. The investigation concluded at the end of the inquest 3-13 June 2024. The conclusion of the jury inquest was a narrative which read as follows: “On the basis of the evidence presented concerning the events of the morning of 26th December 2022, it is probable that the failure to act at that time contributed to the death of Harry, by delaying his transfer to a hospital environment or place of safety. In relation to Harry's medical treatment in the Emergency Department of Southmead Hospital, prior to his transfer to the Mason Unit, the medical evidence deemed him to be medically fit for discharge, at that time. However, it is probable that the failure to take more physical observations, specifically after he had ingested more cocaine and prescribed medication, significantly contributed to the death in that the evidence for his discharge was more likely than not to have been insufficient. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL Given the evidence regarding his treatment in the Mason Unit, it is probable that the failure to perform adequate observations, both physical and non-contact, contributed to Harry's death as, by failing to prioritise the accurate monitoring of his physical condition and therefore identify it's deterioration, an opportunity to transfer him promptly back into the Emergency Department was missed.” The medical cause of death was recorded as: 1a) Sudden death, most likely as a result of terminal cardiac arrhythmia, on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology 4 CIRCUMSTANCES OF THE DEATH Harry Vass was a 24yr old, he had a history of ADHD, poor mental health, psychosis, paranoia secondary to recreational drug use and illicit drug dependency including cocaine. Harry attended the A&E department of Southmead Hospital on 26th December 2022 at 16.42hrs, with the reason recorded as “mental health”, he was expressing paranoid thoughts. He had a high heart rate and was sweating. He underwent a physical assessment and was assessed by the Mental Health Team. At some point he took cocaine in the toilet of the hospital after which he became more agitated and there were concerns being raised that others in the department felt threatened. At one point he absconded from the unit but was brought back, a doctor in the emergency department gave him medication to calm him down. The police were called but when they attended Harry was calm from the effects of the medication. The police were called and attended again when Harry’s agitation increased. It was during this discussion that the police officer raised the possibility of Harry having ABD (acute behavioural disturbance). The police officer said that he’d seen close to a dozen cases, that Harry had similar symptoms. The two mental health practitioners said that they knew very little about ABD. After some discussions with the police officer, the two mental health practitioners and the consultant in emergency medicine Harry was deemed medically fit and he was admitted under s136 Mental Health Act to The Mason Unit (a place of safety) within the hospital at around 23.00hrs. Once on the Mason Unit Harry continued to be distressed and agitated, he was given further medication to calm him. Harry remained disturbed but had periods of calm, he became fearful of isolation, he became sleepy and at around 3.30hrs on 27th December 2022, he vomited. Observations were carried out confirming that Harry had low oxygen saturations and a high temperature. At 4.45hrs his extremities were discolouring, and he became unresponsive, an ambulance was called. He was transferred back to the A&E department but died at 06.36hrs. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL Dr Delaney a forensic pathologist assisted in determining the medical cause of death (noted above). 5 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. – • Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency. • • The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.” 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 13/8/24. 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: • Family of the Deceased • Avon & Wiltshire Mental Health NHs trust • North Bristol NHS Trust • Avon & Somerset Constabulary Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL I have also sent it to The Royal College of Psychiatrists who may find it useful or of interest. 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 M. E. Voisin HM Senior Coroner for Avon 18/6/24 Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
12 August 2024
M. E. Voisin
HM Senior Coroner
The Coroner’s Court
Old Western Road
Flax Bourton
BS48 1UL
By email only to:
Dear Sirs
Dear Ms Voisin
Royal College of Nursing
20 Cavendish Square
London
W1G 0RN
Lynn Woolsey
Deputy Chief Nurse
Telephone:
Email:
Prevention of Future Deaths Report – Harry Roland Ian VASS
We respond to your Prevention of Future Deaths (PFD) Report dated 13 June 2024 following the sad death
of Harry Vass.
With a membership of over half a million registered nurses, midwives, health visitors, nursing students,
nursing support workers, nursing associates and nurse cadets, the Royal College of Nursing (RCN) is the
voice of nursing across the UK and the largest professional union of nursing staff in the world.
RCN members work in various hospital and community settings in the NHS, the independent sector and
in the education sector. The RCN promotes patient and nursing interests on numerous issues by working
closely with the Government, the UK parliaments and other national and worldwide political institutions,
trade unions, professional bodies, and voluntary organisations.
Not all registered nurses, midwives, health visitors, nursing students, nursing support workers and nurse
cadets are members of the RCN. The Nursing and Midwifery Council (NMC) is the independent regulator
for registered nurses and midwives in the UK and nursing associates in the UK. The NMC’s register shows
who can practise as a nurse or midwife in the UK or as a nursing associate in England.
The RCN offers a suite of learning resources to support nurses, students, nursing support workers,
midwives, and health care professionals at all stages of their careers. We provide expert-led, quality-
assured evidence-based education for CPD and learning on a range of topics and subjects.
It is not for the RCN to comment on the performance of any individual nurse or nursing associate.
We note the Matters of Concern set out in PFD as:
I.
II.
III.
It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a
medical emergency.
Due to Harry’s level of agitation, he did not undergo the level of observations that would and
should have happened either in the emergency department or once on the Mason Unit which may
have assisted in assessing his physical health.
The decision as to whether a person has ABD is important, Dr Delaney said that” this group are
vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a
body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute
disturbance in behaviour the body loses control of these safe parameters”.
We will respond, as far as we are able to each concern in turn:
I.
It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a
medical emergency.
In situations where ABD (Agitated or Aggressive Behaviour Disturbance) is observed, it is important to
note that this describes a person's behaviour and not a specific diagnosis. However, there are limited clear
guidelines on the necessary observations in such cases. The Royal College of Psychiatrists has published a
position statement regarding (‘ABD’) and ‘excited delirium’ (‘ExD’), emphasising multi-professional and
cross-service collaborative working.1 It concludes:
“Staff working in mental health services, including psychiatrists, manage extremely agitated and
distressed patients on a daily basis across crisis, liaison, addictions, forensic and psychiatric intensive care
services. Joint protocols and more robust training should be in place across services to ensure the care
received by patients who are severely agitated and distressed is truly multi-disciplinary.”
When someone presents with agitated behavioural challenges (as described by ABD), traditionally,
emergency department staff rule out physical health reasons before contacting psychiatric services. This
includes examinations such as infection indicators, CT scans for head injury, and drug screening, terming
the phrase ‘medically fit’.
However, such terms do not safeguard against diagnostic overshadowing or missed medical diagnosis and
risk giving false reassurance in place of an adequate clinical history, physical examination and
1 https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/position-
statements/ps02 22.pdf
investigations as indicated.2 In such circumstances where a patient is classed as ‘medically fit’, mental
health nurses in secondary services may be less likely to consider further agitated behaviours as physical
health-related.
II.
III.
Due to Harry’s level of agitation, he did not undergo the level of observations that would and
should have happened either in the emergency department or once on the Mason Unit which
may have assisted in assessing his physical health.
The decision as to whether a person has ABD is important, Dr Delaney said that” this group are
vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background
a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute
disturbance in behaviour the body loses control of these safe parameters”.
The RCN cannot comment on the specific factors in the emergency department or the Mason Unit that
may have contributed to Harry’s tragic passing.
We agree with Mr Delaney’s statement. However, as stated above, ABD is neither a formal diagnosis nor
explicitly embedded in nurses' proficiencies for professional practice.3 The only inferred related
proficiency could be:
“4.10 demonstrate the knowledge and ability to respond proactively and promptly to signs of deterioration
or distress in mental, physical, cognitive and behavioural health and use this knowledge to make sound
clinical decisions.”
However, this standard does not adequately encompass the specific complexities as described by ABD.
Although now a legacy statement, it was indirectly in the 2014 field-specific competencies as:
“Acts autonomously and appropriately when faced with sudden deterioration in people's physical or
psychological condition or emergency situation, abnormal vital signs, collapse, cardiac arrest, dehydration,
self-harm, extremely challenging behaviour, or attempted suicide. OAC9,20.” toc-14-blueprint---mental-
health-nursing.pdf (nmc.org.uk)
According to the NICE guideline (NG10, 2015), physical observations should be conducted after the
administration of rapid tranquilisation regardless of the causes of agitation. However, the impact and
interactions of recreational drugs in this scenario are not well understood. In the absence of evidence,
nurses and other medical staff may make professional judgments of evidence in clinical decision-making.
Beyond calls and actions at the individual or micro-level, such as awareness, education and training,
broader systemic and cultural considerations are necessary. Staffing levels, skill mix within the team,
clinical and policy governance, procedures, escalation plans, raising concerns, management of
deteriorating patients, patient safety reviews, and how organisational learning is undertaken following
mortality and morbidity reviews must be actioned.
2 https://www.rcpsych.ac.uk/docs/default-source/members/faculties/liaison-psychiatry/liaison-sidebyside.pdf
3 https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-nurses/
According to the NMC annual report4, 27,168 people left the register in the last year, slightly fewer than
the previous year. Of those who left, 20.3% (5,508) were nursing and midwifery professionals who left
within the first ten years of starting their careers. This percentage has increased for the third consecutive
year, up from 18.8% in 2020-2021. Additionally, 49% of those who completed the leavers survey indicated
leaving their profession earlier than expected. Nursing staffing levels directly impact patient safety. We
can’t improve one without improving the other. The RCN’s Nursing Workforce Standards are a roadmap
for designing a workforce that can offer patients high-quality care.5
Many nurses are caring for too many numbers of patients and facing overwhelming pressure and
burnout. The correct number of nursing staff with the right skills must be in the right place at the right
time.6 A 2024 report by the University of Bath identifies psychological stress, workload, staff shortages,
and pay as the top reasons for staff leaving the NHS. Rising burnout symptoms, declining job satisfaction,
and low confidence in improving working conditions were also observed. Additionally, the proportion of
NHS nurses recommending working for the NHS to others has significantly decreased, highlighting
significant retention concerns.7
We hope you find these comments helpful.
Yours sincerely
Deputy Chief Nurse
4 https://www.nmc.org.uk/about-us/reports-and-accounts/annual-reports-and-accounts/
5 https://www.rcn.org.uk/Professional-Development/Nursing-Workforce-Standards
6 https://www.rcn.org.uk/employment-and-pay/Safe-staffing/Safety-critical-nurse-to-patient-ratios
7 https://www.bath.ac.uk/announcements/nearly-a-third-of-nhs-staff-are-requesting-details-of-jobs-outside-the-
nhs/
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