Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0456, written 13 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 | 13 Aug 2024 |
|---|---|
| Reference | 2024-0456 |
| Deceased | Matthew Gale |
| Coroner | Simon Connolly |
| Coroner area | County Durham and Darlington |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 , Chief Executive, Tees Esk and Wear Valleys, NHS Foundation Trust 1 CORONER I am Simon CONNOLLY, Assistant Coroner for the coroner area of County Durham and Darlington 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 24/03/2023 18:22an investigation was commenced into the death of Matthew Clive GALE 11/10/1985 00:00:00. The investigation concluded at the end of the inquest on 23/05/2024 14:17. The conclusion of the inquest was that Matthew’s death occurred on 19th March 2023 at health dating back to June 2017 including periods as a patient in West Park Hospital. . Matthew had a history of mental ill- Matthew had a schizoaffective episode in February 2023 and was admitted to Maple Ward of West Park Hospital. Treatment plans were put in place but Matthew’s condition deteriorated from 6th March 2023 and he was formally detained under the Mental Health Act on that day. He was granted Section 17 leave on the 8th March but there are no records to support this. The conditions of his leave were widened and incorrect forms were used and the conditions were not conveyed to Matthew’s family. The salient condition was that Matthew should not be left alone and the failure to communicate contributed.. 4 CIRCUMSTANCES OF THE DEATH Matthew’s death occurred on 19th March 2023 at had a history of mental ill-health dating back to June 2017 including periods as a patient in West Park Hospital. . Matthew Matthew had a schizoaffective episode in February 2023 and was admitted to Maple Ward of West Park Hospital. Treatment plans were put in place but Matthew’s condition deteriorated from 6th March 2023 and he was formally detained under the Mental Health Act on that day. He was granted Section 17 leave on the 8th March but there are no records to support this. The conditions of his leave were widened and incorrect forms were used and the conditions were not conveyed to Matthew’s family. The salient condition was that Matthew should not be left alone and the failure to communicate contributed. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: (brief summary of matters of concern) At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form. The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data. Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria. Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought tot be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system. The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken. 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 September 13, 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 Watson & Woodhouse Solicitors I have also sent it to who may find it useful or of interest. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 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: 13/08/2024 Simon CONNOLLY Assistant Coroner for County Durham and Darlington 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.
Office of the Chief Executive
West Park Hospital
Edward Pease Way
Darlington
County Durham
DL2 2TS
11th October 2024
Private and Confidential
HM Assistant Coroner
Mr Simon Connolly
By email:
Inquest into the death of Matthew Gale
I am writing to you in response to the Report to Prevent Future Deaths (PFD), served on the Trust on 16
August 2024, in relation to compliance audit data relating to Section 17 leave. Our Chief Nurse has been
working with the Care Group Directors of Nursing, Medical Directors and Directors of Therapy to ensure
that the Trust have consistent oversight of daily performance and the improvement trajectory around
Section 17 leave, which is reported to the Board of Directors.
As previously advised, following the May 2024 audit results the Trust implemented the following to improve
Section 17 leave requirements:
- The weekly Fundamental Standards Group for all inpatient staff have amended its agenda to focus
purely on quality assurance audit results to enable audit results to be discussed, with agreed actions
identified for matrons and managers.
- Section 17 leave and communication with families/carers around the responsibilities of the
accompanying role has been added to the Trust wide preceptorship package, which is required to be
undertaken by every registered nurse who joins the Trust.
- The Trust continue to work with families to focus on the importance of carers, families and loved ones
and their involvement in care.
-
In June 2024 a task and finish meeting was arranged to discuss the May audit results to develop a
more frequent auditing process at ward level to monitor compliance with Section 17 leave
requirements, develop a training package for all staff and to review the Section 17 leave policy. Since
the development of this task and finish meeting, the Trust have done a significant amount of work to
improve Section 17 leave compliance.
The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a
decision made that the Section 17 leave form and leave/time away from the ward monitoring form will
remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by
both the patient and accompanying person, to ensure they are aware of the conditions of leave and each
person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a
copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been
Chief Executive:
Chair:
1
amended and now includes sections to identify the name of the accompanying person and they now have
to sign to confirm that they are aware of the leave conditions prior to each period of leave.
The changes to the Section 17 leave policy has been discussed at Quality Board, which included a
representative from the Integrated Care Board, NHS England and the Care Quality Commission, who all
approved of the changes.
The Associate Director of Nursing and Quality has developed and delivered targeted training to all
Associate Directors of Nurses (ADONs) around Section 17 leave, including the changes to policy and
procedures and the need to ensure that processes are being followed and documented. This training is
currently being disseminated across the relevant parts of the Trust with oversight of the ADONs. Within the
last three weeks, 957 (70%) of substantive ward staff within the Trust have been trained in the new Section
17 leave policy. In addition to this, Section 17 leave/time away from the ward training has been delivered to
temporary workers, community staff, corporate services, and professional groups to ensure they are aware
of the changes. Compliance with training continues to be closely monitored by the ADONs to ensure the
Trust captures all relevant staff.
The ADONs have all been provided with a checklist to complete which requires them to confirm that the
updated Section 17 leave policies have been shared with all relevant staff that they have responsibility for
and that this has been included as a topic at multi-disciplinary team meetings, for a period of 2 weeks, to
raise awareness of the changes in policy in addition to the requirements of staff to attend the Section 17
training.
In order to further assist staff with the requirements of Section 17 leave, staff have been provided with
leave folder templates and contact cards, which are now in use across the relevant parts of the Trust. At
the front of the leave folders is a flowchart that has been produced to remind staff of the requirements of
Section 17 leave. The leave folder also contains a copy of the most recent Section 17 leave form and the
leave/time away from the ward monitoring form to enable easy access. Contact cards are now also given
to the patient and the accompanying person, which have details of the ward contact details, any conditions
of leave, a check that a copy of the section 17 leave form has been provided and details of time and date
which patient is due to return.
The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave
procedures and an assessment will be made to determine the impact of the Section 17 leave policy
changes, which was approved on 10 September 2024 by the Trust's Executive Team.
We hope that the above demonstrates that the Trust are continuously working to improve processes
around Section 17 leave and will continue to monitor this closely to ensure the changes are embedded.
Yours sincerely
Chief Executive
Chief Executive:
Chair:
2
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