Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0449, written 25 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Mar 2024 |
|---|---|
| Reference | 2024-0449 |
| Deceased | Alexander Lyalushko |
| Coroner | Amanda Bewley |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Suicide (from 2015) |
| Organisation named | Nottinghamshire Healthcare 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 REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust 1 CORONER I am Amanda Bewley, Assistant Coroner, for the coroner area of Nottingham and Nottinghamshire 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 12 March 2023, I commenced an investigation into the death of Alexander Vitali Lyalushko. The investigation concluded at the end of the inquest on 15 March 2024. The conclusion of the inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH Mr Lyalushko took his own life by hanging, intending to end his life, on 2 January 2023. Mr Lyalushko died at his home address where he lived alone. My Lyalushko was a vulnerable young man with diagnoses of autistic spectrum disorder, anxiety, depression and agoraphobia. Mr Lyalushko was known to express suicidal ideation and had made suicide attempts. Mr Lyalushko had extensive involvement with mental health services throughout his life, including with Gedling Local Mental Health Team under Nottinghamshire Healthcare NHS Foundation Trust from August 2015 to August 2019, and from July 2020 to March 2022. A request for the involvement of Gedling Local Mental Health Team with Mr Lyalushko was sent to the service by Mr Lyalushko’s General Practitioner on 22 November 2022. For reasons which have not been ascertainable, no action was taken in response to that request. Mr Lyalushko took his own life a little over a month later, there being no involvement of mental health services with him at the time of his death. Detailed findings as to how Mr Lyalushko came by his death are described within a written determination dated 15 March 2024, appended to this report 5 CORONER’S CONCERNS 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: Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. Inadequate review and incident investigation following a death Following Mr Lyalushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks). I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalushko: it did not identify that a request from Mr Lyalushko’s GP in November 2022 for involvement of its service with Mr Lyalushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalushko’s family to consider whether there were any areas of concern they had which might direct elements of the review. If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances. I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place. 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 20, 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. Mr Lyalushko’s family I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I will send a copy of my report to the Care Quality Commission. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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: 25/03/2024 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Amanda BEWLEY Assistant Coroner for Nottingham City and Nottinghamshire 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.
Nottinghamshire Healthcare NHS Foundation Trust Duncan Macmillan House The Resource Porchester Road Mapperley NG3 6AA Tel: 20 May 2024 Private and Confidential HM Assistant Coroner Amanda Bewley Dear Miss Bewley Regulation 28 Response: Mr. Alexander Lyalushko I write in response to the inquest which was held from the 12th to the 15th March 2024 into the death of Mr Alexander Lyalushko. We accept your findings in relation to the received Regulation 28. We are very sorry that after the death of Alexander it later emerged that the GP had communicated with the Trust requesting engagement by the Local Mental Health team and furthermore that this was not attempted or known due to a technical issue and the letter not being responded to. We extend our apologies to the family of Alexander and for the distress this has caused as a result. Please find below the Trust response and actions taken. Inadequate Review and Incident Investigation Following a Death. I would like to assure you that we take all deaths very seriously and seek to learn through a variety of methodologies. The methodologies are based on the initial fact find and review of the case records but also can be based on what service the patient was seen by and when the last contact occurred. Specifically, in relation to Alexander, I have been advised that the decision making was based on the understanding that he had been out of Trust services for approximately 9 months and at the time, there were no known concerns raised by his family at the time that either the Patient Safety, or Inquest Team were aware of. A Case Note Review (CNR) was therefore agreed to review his care and treatment and to identify any learning. A CNR requires the author to review the clinical record only. We unfortunately recognised during preparation for the inquest that the GP for Alexander had made a referral in November 2022 and that this was not actioned. This referral was not in the Trust clinical The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA record and therefore unavailable to the author of the CNR. This information became known about in January 2024 and agreed that this would be dealt with via a statement from the relevant team leader. This statement was to confirm that this referral was not available or known to the author of the CNR, confirm what had occurred, confirm what should have happened according to procedure, and what had since been put in place to reduce risk of recurrence. It was subsequently agreed at the inquest that a further review would be undertaken and addendum to the report added to take into account this information that was not known at the time of the original CNR, as well as the additional points raised within the findings and conclusion document provided to the Trust. This is being undertaken and nearing completion. We will share this once completed with you and the family of Alexander, who have been involved in the onward investigation process. Once completed we will be better sighted to understand the wider lessons learnt and actions required to mitigate future occurrence and ensure the correct oversight is deployed. Moving forward, Nottinghamshire Healthcare NHS Trust are transitioning to the new Patient Safety Improvement Framework. As this transition progresses, the way in which we approach the review of care for deaths likely to be subject to inquest will change and we are working with HM Coroners to ensure that this transition is smooth and meets the needs of the Coronial enquiry. I hope that the information contained within this response provides assurance to you and Mr. Lyalushko’s family that we have heard and understood the concerns raised and continue in our journey to make improvements subsequent to this process for future patient care. Yours sincerely Executive Director of Nursing, AHPs & Quality The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
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