Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0340, written 26 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 | 26 Jun 2024 |
|---|---|
| Reference | 2024-0340 |
| Deceased | Nicola Lacey |
| Coroner | Hugh Gregory |
| Coroner area | Herefordshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
d n a g n i d r a u g e a f s e h t , s s e c o r p e h t t u o h g u o r h T . d e r e d i s n o c e b t s u m s e i t r a p l l a f o s d e e n t r o p p u s MANAGING CONCERNS AND ALLEGATIONS AGAINST PEOPLE WHO WORK WITH ADULTS WITH CARE AND SUPPORT NEEDS WITHIN HWHCT Process for dealing with the concern about the person in a Position of Trust (POT concern) Concern can be identified or raised in different ways E.g. Concern raised through partner / agencies (Social Care, Police etc) E.g. Member of the public or other 3rd party informs the partner / agency. E.g. Concern is raised through information gathering with the person E.g. Via third party health agencies (acute / GP services) Concern or allegation is shared with the Trust. An initial Panel meeting between the manager of the person against whom the allegation has been made, a member of HR, a member of IST and the relevant professional lead will be called within 24 hours (Monday to Friday*) to consider the allegation. *For Out of Hours (OOH) guidance, please see seperate process chart. The information indicates an identifiable adult with care and support needs, or child, is experiencing or is at risk of abuse or neglect- REFER TO / USE ADULT or CHILD SAFEGUARDING PROCESSES The Panel assesses the risk, and may investigate allegations through internal employment processes where it is appropriate to do so The Panel ensures that risk management actions as appropriate to the individual case are undertaken and an appropriate action plan is formulated and completed (e.g. increased supervision or monitoring, redeployment whilst the investigation is completed, disciplinary or dismissal). Ongoing management of the individual against whom allegations have been made will be delivered via the Operational / Clinical management structure in consultation with Human Resources and Professional Leaders as appropriate. The Panel considers making a notification of the disclosure to external agencies and / or regulator e.g. - ICB - Local Authority - NHSP - CQC (when employed in a CQC regulated service) - OfSTED (when employed in an OfSTED regulated service) - DBS - Professional bodies like the HCPC, NMC, GMC Commissioning and regulatory agencies can check/oversee employer actions as part of regulatory and contract monitoring processes.
Ensure staff member is made aware, ensure shift is covered Ensure that in Hours staff are made aware prior to staff member coming on shift Receiving team ensures that - Initial safety planning is completed for all involved. Medical care is offered if needed. Consider risk to others/ public. Consider informing family. Consider contacting police if a criminal act has occurred. Retain CCTV and other evidence OOH POT Level 2 should consider seeking supervision from Level 3 if needed Possible POT referral received by clinical team Receiving team discusses with appropriate manager Manager ensures that Level 2 on call is informed of/party to discussions Level 2 Manager ensures that anonomised allegations are detailed in on call log and a seperate confidential written record is kept On call manager hands information over to 'in hours' operational manager and emails Whcnhs.integratedsafeguarding @nhs.net with update and hands over to operational team Does the staff member subject to the allegations need to be removed from shift? The information indicates an identifiable adult with care and support needs, or child, is experiencing or is at risk of abuse or neglect- REFER TO / USE ADULT or CHILD SAFEGUARDING PROCESSES
H G Mark Bricknell Senior Coroner for County of Herefordshire 26th June 2024 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Robert Mackie, Chief Executive, Herefordshire and Worcestershire Health and Care NHS Trust. CORONER 1 I am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.u k/u ksi/2013/1629/pa rt/7 /made 3 INVESTIGATION and INQUEST On 13 January 2023 I commenced an investigation into the death of Nicola Jane LACEY. The investigation concluded at the end of the inquest on 12 June 2024. The conclusion of the inquest was suicide. CIRCUMSTANCES OF THE DEATH 4 Nicola Jane Lacey lived alone in a large property in rural Herefordshire. She had recently separated from a partner. On the 30th December 2022, the deceased did not attend work and did not call anyone. This raised concern. As a consequence a member of staff who worked with the deceased attended her address. There was no answer at the address and therefore the Police were called. Police attended the scene and forced entry. The Police established that Nicola Jane Lacey had died. A note identified the deceased's intentions. Nicola Jane Lacey had a responsible position within Healthcare.
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.
Chief Executives Office 2 Kings Court Charles Hastings Way Worcester WR5 1JR Tel: 01905 681667 Email: 20th August 2024 HM Senior Coroner- HG Mark Bricknell HM Coroner’s Office Town Hall St Owen Street Hereford HR1 2PJ Sent via email to: Dear Sirs, Re: Regulation 28: Report to Prevent Future Deaths in respect of Ms Nicola Lacey I am writing in response to your report to prevent future deaths dated 26th June 2024 addressed to me, I am grateful for the opportunity of responding to your concerns. The Trust is always keen to learn from any tragic incident and I hope that this response satisfies you that we have reviewed the issues raised appropriately. Your concern: Procedures should be clear and known to employers concerning appropriate disclosure of a colleagues ongoing mental health difficulties for the benefit of both the individual concerned and the safety of the wider public. The Trust can confirm that when working with patients with ongoing mental health difficulties we routinely assess the risks associated with themselves and others. If it is identified that this risk relates to or is relevant to their employment, we would in the first instance discuss this with the patient and seek informed consent for the employer to be advised of any necessary concerns. The importance of a therapeutic relationship is critical to supporting patients in their recovery. If a patient does not agree to discussions taking place with their employer about their health, practitioners have very clear parameters when they need to consider if they should breach confidentiality. In order to support such a decision, our clinical staff have access to both management and clinical supervision, safeguarding supervision, as well as access to other professional advice such as through our legal or information governance teams, or our Caldicott Guardian. If we have any concerns about anyone who works or volunteers with adults with care and support needs we would also consider this in regards to ‘A Person in a Position of Trust’ (PiPoT) framework. Chief Executive: Chair: The Person in a Position of Trust Framework is applicable where there is an allegation or concern about an adult who works or volunteers in a position of trust with adults with care and support needs, employers, student bodies and voluntary organisations. In Herefordshire this framework is agreed and overseen by the Herefordshire Safeguarding Adult Board and a copy can be found here Positions-of-Trust-Framework-1.pdf (herefordshiresafeguardingboards.org.uk) In this situation where concerns arise the clinical team notify our Safeguarding team who then co- ordinate an appropriate discussion with professional advice and a decision is made using the Position of Trust Framework as to whether information is shared with an employer or not. Action: To ensure this process is clear, known to staff and followed routinely we have developed 2 Standard Operating Procedures (SOPs), one within working hours and one for out of hours. These SOPs are now in place and will be added to our Position of Trust Policy. Please find both SOPs attached for your information. In addition, I can confirm the author of the report who adduced oral evidence at court has been contacted to ensure she is happy with the above process. As an organisation, we always prioritise the mental health and well-being of our staff. We understand that mental health is just as important as physical health, and we are committed to creating a supportive and inclusive work environment that promotes mental wellness. We hope the above reassures you that we do offer resources and support for employees who may be struggling with mental health concerns. Our goal is to ensure that all staff members feel supported valued and able to thrive both personally, and professionally. We believe that by promoting mental health we create a positive and protective work culture for everyone. Conclusion: I would like to thank you for drawing this matter to my attention, I confirm that the point you raised has been carefully considered and the response set out above. I confirm that I have no submissions to make about publishing this response. If you have any further queries do not hesitate to contact me. Yours faithfully Chief Executive Enc
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