Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0422, written 1 Aug 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 Aug 2024 |
|---|---|
| Reference | 2024-0422 |
| Deceased | Kieran Lavin |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| 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.
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Health NHS Foundation Trust
CORONER
, Chief Executive, Birmingham and Solihull Mental
I am Mr James Bennett, Area Coroner for Birmingham and Solihull.
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.
INVESTIGATION and INQUEST
On 2 January 2024 I commenced an investigation into the death of Kieran Lavin. The investigation concluded
at the end of the inquest held between 22-25 July 2024.
CIRCUMSTANCES OF THE DEATH
Kieran had experienced anxiety and depressive symptoms for around 10 years with worsening symptoms in
late 2023. In November he consulted his GP having inadvertently stopped taking his anti-depressant
medication. On 5/12 he reported worsening symptoms after restarting his medication for two weeks, and said
he had thoughts of jumping in front of a vehicle and an overdose, citing the breakdown of his relationship
with his wife as one of the triggers. He was referred to the Crisis team and assessed on 7/12 reporting no
active suicidal plans. His anti-depressant medication was increased, and he agreed to be seen routinely in 4
months. The following day, on 8/12 he booked into a hotel to overdose on his medication with alcohol. He
was surprised to wake up and was admitted to the Emergency Department early on 9/12. Psychiatry & Liaison
referred him to the Psychiatric Decisions Unit ('PDU') for further assessment as he could not guarantee his
safety. He arrived at the Oleaster Centre, Birmingham at 9:55pm. The following day, early morning on 10/12
during a nurse assessment he said he was angry the overdose attempt had not worked, and if he went home,
he would maybe throw himself in front of a lorry. He cited in part the relationship breakdown with his wife as
one of the triggers for his presentation. Later that day, he was assessed by a consultant psychiatrist whose
impression was of a depressive episode, and that Kieran required informal admission as he did not feel safe to
go home, which Kieran agreed with. The following day, by 11am on 11/12 Kieran proactively contacted a
second nurse reporting when outside the unit for a cigarette he had terrible thoughts, and he does not feel
safe going outside because he thinks he needs to kill himself and he will run and jump in front of a car or train.
Around 1-2pm he was assessed by a junior Dr and reported no active suicidal plans, but her impression was he
was very anxious and depressed, and the plan was maintained. The long wait for a bed was due to the mental
health service having no available inpatient bed. A private mental health service agreed to admit him in
Willenhall. Kieran's wife had arrived to drop off some clothes and Kieran asked if his wife could drive him. The
bed manager, also the nurse in charge of the Oleaster Centre, had intended that Kieran be transported via taxi
accompanied by a member of staff, but agreed to his wife driving him on the basis Kieran was a voluntary
inpatient, wanted treatment, and assessed his presentation on and off the PDU as raising no safety concerns.
He did not record his risk formulation. He was not aware of the two reports of suicidal ideation via road traffic
collision. Had he looked at the 'level 1 risk screening' neither nurse had at this stage updated the 'suicide' box.
No record of his suicidal ideation on 10/12 was ever added, and the suicidal ideation reported on the morning
11/12 was not added until 8:51pm and after the incident had occurred. Whether his wife's presence would
exacerbate Kieran's presentation was not fully considered, or the length and nature of the journey. His wife
was not informed of Kieran's reported suicidal ideation. The mental health service's policies, procedures and
guidelines did not set out a clear approach to assist regarding what should happen when a patient requests
for family to transfer them to another location for an informal admission. Kieran left with his wife in her car
around 7:45pm. Shortly after 8pm, having just spoken on the phone to his mum, he suddenly proceeded to
open the passenger door whilst in lane 1 of the M5 motorway. His wife attempted to physically stop him
OFFICIAL
whilst managing to move to the hard-shoulder whereby Kieran exited the passenger door and walked around
the rear of the car into the path of an oncoming large lorry in lane 1, and thereafter was struck by a second
car. He was confirmed deceased at the scene from the consequential injuries (1a. Multiple injures).
The inquest conclusion was: “Suicide, contributed to by a failure to conduct an adequate patient transport risk
assessment which would have likely changed the outcome.”
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. –
1. Critical suicide risk information was not recorded at all or not recorded in a timely manner. On
10/12/23, the experienced nurse did not record at all in the ‘suicide’ box on the ‘level 1 – risk screening’
the first report of suicidal ideation via road traffic collision. She described this omission as an error and
the likely explanation was that she was the only nurse working on a very busy shift. On 11/12/23, the
experienced nurse did not in a timely manner record in the ‘suicide’ box on the ‘level 1 – risk screening’
the second report of suicidal ideation via road traffic collision received by 11am. She said the likely
explanation for not updating the ‘suicide’ box until 8:51pm (and after the nurse-in-charge made his
transport risk formulation) was that she was the only nurse working on a very busy shift. The
experienced Nurse-in-Charge did not record at all his transport risk formulation saying that was not his
usual practice. The Patient Safety Manager said long standing trust policy required clinicians to record key
information as soon as possible. I am not persuaded this long standing policy is sufficient by itself to
remove the risk in the future of critical suicide risk information not being recorded at all or in a timely
manner given three experienced nurses within 24 hours failed to follow the policy.
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2. Post-death trust learning led to new guidance for when an informal patient requests family, carer, or
friend transport them from PDU. For ease of reference it states:
“Where appropriate, it is reasonable for the option of an informal patient to be transported by
family/carer/friends. In all such cases, decision needs to be based on the risk/benefit ratio and this also
needs to be clearly discussed with the person transporting to make sure there is understanding and
agreement. This needs to be clearly documented within the patient’s notes. If there is any concern or
disagreement expressed by the person, family/carer/friends, then alternative arrangements need to be
made by us.”
I am not persuaded this is sufficient to remove the risk of an inadequate risk assessment in the future. By
way of contrast, trust guidance C52 ‘Mental Health Act Transport of Patients’ - which applies when a
patient has been assessed under the Act and ambulance service transport is to be used - at paragraph 12
includes 15 specific questions that the risk assessor should ask as part of the transport risk formulation,
including: How far does the patient have to travel? What is the patients age and gender? What is their
current state of mind? Is there a risk to the driver/accompanying individuals? The updated guidance cited
above is absent any equivalent specific questions or assistance on when it is or is not appropriate. For
example, in Kieran’s case clinicians were aware his sex, age, and background of relationship breakdown
statistically recognised him as being at a higher risk of suicide, PDU is only intended for a brief stay
whereas Kieran was there for nearly 48 hours and his state of mind was not assessed in the hours before
the risk formulation (even thought it was known to fluctuate), the journey if considered would have been
noted to take him away from local roads onto a high speed motorway, and his wife/the driver was known
to be a trigger for his low mood. Further, there was no consideration of what his wife had to be told to
ensure she was safe, providing genuine informed consent given the interplay of patient confidentially. In
Kieran’s case the transport risk formulation did not consider whether his risk of suicide included road
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traffic collision vs an unrelated mechanism. My concern is the above cited guidance in simply stating the
decision should be based on ‘appropriateness’ and ‘the risk/benefit ratio’ does not sufficiently prompt
clinicians to consider the full range of key issues and is inconsistent with the more expansive guidance in
C52 for when an ambulance is to be used.
For completeness, (1) there was discussion during the inquest about why there cannot be a blanket ban
on informal patients with recent suicidal ideation via road traffic collision being transported by family etc
given they represent a very small cohort of patients. If no such ban is considered appropriate, in my view,
the need for more expansive and specific guidance for clinicians equivalent to C52 is increased, and (2)
there was discussion at the inquest of a transport risk formulation based on a points system with a
written draft suggestion from the Family’s counsel; I attach a copy which may be of assistance for the
trust when deciding what if any action to take.
ACTION SHOULD BE TAKEN
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In my opinion action should be taken to prevent future deaths and I believe you 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 26
September 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1. Kieran’s family.
2. Insurers:
.
I have also sent it to
who may find it useful or of interest.
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, Chief Executive, NHS Birmingham and Solihull Integrated Care Board
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 August 2024
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James Bennett
HM Area Coroner for Birmingham and Solihull
OFFICIAL
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.
Head Office Uffculme Centre 52 Queensbridge Road Birmingham B13 8QY Tel: Mr James Bennett Coroner for Birmingham and Solihull Steelhouse Lane Birmingham B4 6BJ Our Ref: Your Ref: Date: 26 September 2024 Sent via email only: Dear Mr Bennett, RE: PREVENTION OF FUTURE DEATH KIERAN MICHAEL LAVIN I write in response to the Prevention of Future Death report dated 1 August 2024. I would like to begin by offering my sincere condolences to the family of Mr Lavin. I would like to take this opportunity to assure both the Coroner and the family that we have taken the concerns that you have raised very seriously and have taken necessary steps to learn from these. I will aim to address each of the points that you raised within your report in turn. Documentation concerns You flagged two areas of concern within this aspect, one was around recording of important information and the timely recording. The second related to your concerns around the risk associated with staff not complying with the trust’s policy on documentation. With the above in mind, we will be setting up regular Risk Huddles which will include the psychologist, which will be on a monthly basis (the frequency can be increased if the need arises). Risk huddles proactively manage quality and safety, enabling teams to focus on developing / reviewing risk formulation using the 5P's (Presenting, Predisposing, Perpetuating, Participating, Protective) model and formulate plans for service users. The aim is to raise the understanding and quality of risk formulations. Comprehensive risk formulation consistently improves quality of care and risk management of patients. We do however acknowledge that communication could be improved through improvements in relation to documentation and therefore we also have a reflective session for the staff in the Urgent Care Centre [which includes the Psychiatric Decisions Unit (PDU)] to further explore the staff members’ thoughts and feelings around various issues including risks and any actual and perceived barriers that may be faced. This took place on 16 September 2024. Chair: │ Chief Executive: │ Website: www.bsmhft.nhs.uk Customer Relations: Mon–Fri, 8am–6pm │ Tel: │ Email: The quality and standards of the handover process in the PDU will be reviewed, with particular attention to ensuring that critical information is documented and communicated before key decisions, such as patient transport, are made. The handover process will also be revised to establish clear standards that require the documentation and communication of urgent information prior to any significant decisions, including patient discharge. Review of risk for informal patients transported by family members In response to the risk assessment for transfer of informal patients, as earlier noted; the learning in this respect was also in relation to communication. I would like to begin by thanking the family for their suggested checklist for this risk assessment. We are grateful for this offer. The factors identified in the checklist submitted by the family barrister includes risk factors that would and should be considered in a risk assessment and management conversation. However, it would not be possible to score these as this would be an arbitrary process, with no grounding in research or evidence based clinical practice. Given the areas of risk that need to be considered, having such a prescriptive list could potentially result in staff members omitting to review key areas of risk that may not be indicated on the list, thereby inadvertently replacing comprehensive clinical risk assessment and management processes, which would have serious negative impact on the quality and safety of patient assessment and management. The established research evidence, supported by NCISH data, NHS England, National Collaborating Centre for Mental Health and Royal College of Psychiatrists, is clear that Tools that seek to stratify or score patients have a very low positive predictive value (PPV). The PPV % quoted is in the range of 5% i.e. only 5% of the times, such tools will accurately predict or identify risk; 95% of the times, they do not. Furthermore, research evidence is clear that no one tool is better than another. Individual and personalised approaches to identification of risk factors for an individual, with clear identification of appropriate mitigations, open discussion with patient and relevant families and carers, with a collaborative and mutually agreed plan with a view to optimising safety and reducing risk, is the evidence-based approach (referenced by NICE Guidance). NICE have warned against the use of unvalidated suicide risk assessment tools. Consequently in response to your concerns the Trust have carefully considered the additional ways in which we can assure that staff are carefully considering risk on a case-by-case basis. Meetings have been undertaken with the Executive Medical Director, Deputy Medical Director, Clinical Director for the area and, other key Senior leaders to discuss this area of improvement. We have agreed that the action points noted above will also address this area of concern. In addition, further Risk Assessment training is available for any staff that may need it (identified by the individual and/ or in supervision). The findings of the investigation into the Mr Lavin’s death and the inquest have been shared with staff in urgent care in our Clinical Governance Committee meeting. In addition, we will also arrange focussed meetings with staff in the PDU and Urgent Care Centre to discuss the findings further, in order to promote better understanding and working so as to improve the quality and safety of patient assessment and management in so far as is possible. Since Mr Lavin’s death, we have appointed to a newly-created post of Urgent Care Team Manager (Band 8A nurse) who will be able to provide closer and tailored supervision to our staff, both as a team and individually. As already conveyed to you, we have updated our Transport Policy to emphasise that an open and thorough discussion needs to be had with any family member/friend/carer prior to agreeing the transport of the patient by them. The option for patients to be transferred in this manner will remain, as that upholds the dignity and autonomy of the patient, and is in the spirit of least restrictive practice. This continues to enable patient choice and inclusion in decisions about them. Allowing for this, where appropriate, is also reassuring to the patient and family, and can significantly improve patient experience and outcomes, particularly in but not limited to the early period following admission. The changes made will strengthen the communication and handover processes through the increased knowledge and support from the Risk Huddles. This will improve the quality of the risk assessments and feed into the changes already made to the policy. This will improve the overall safety culture within the Trust. If you have any further questions, please do contact me. Yours sincerely Chief Executive BSMHFT
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