Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0467, written 22 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 | 22 Aug 2024 |
|---|---|
| Reference | 2024-0467 |
| Deceased | Elise Walsh |
| Coroner | Andrew Hetherington |
| Coroner area | Northumberland |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANDREW HETHERINGTON H M Senior Coroner for Northumberland County Hall, Morpeth, Northumberland NE61 2EF Tel Ca REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust CORONER | am Andrew Hetherington, Senior Coroner for Northumberland. CORONER’S LEGAL POWERS | 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://legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST | commenced an investigation into the death of Elise Walsh Deceased. The investigation concluded at the end of the inquest on 20 August 2024. The conclusion of the inquest was a narrative conclusion: The deceased died after ii >: 12 February 2022. The act was deliberate on her part intending the result being to end her life. She suffered severe hypoxic brain injury which left her severely debilitated and died on 7 June 2023. The cause of death was: 1a Aspiration pneumonia 1b Hypoxic ischemic encephalopathy secondary to hanging CIRCUMSTANCES OF THE DEATH The deceased had a history of self-harm and suicidal ideation. On 28 January 2022 she approached police and’ expressed suicidal ideation. She was seen by ‘the Psychiatric Liaison Service and referred to the Crisis Resolution and Home Treatment Team. She voluntarily attended appointments at St George’s Park Hospital for home treatment with transport to and from appointments provided by taxi. She attended an appointment at St George’s Park Hospital on the 12 February 2022. She entered the waiting area toilets and after approximately 16 minutes Po CPR was commenced and she was conveyed to the Royal Victoria Infirmary, Newcastle upon Tyne where it was identified she had sustained a severe hypoxic brain injury which left her severely debilitated bedbound, non-verbal and was fed via a percutaneous gastrostomy tube. She was a resident at Heatherfield Care Home and dependent on staff for all I her needs. She became unwell on 4 June 2023 having developed aspiration pneumonia and was admitted Northumbria Specialist Emergency Care Hospital, Cramlington where she died on 7 June 2023. CORONER’S CONCERNS 1. The deceased attended an appointment at St George’s Park Hospital on "the 12 February 2022. After the appointment she was waiting for a taxi, walking up and down the corridor and appeared to be getting more agitated. She was not happy with how her appointment went and voiced those concerns verbally. When the taxi arrived, she refused to get in and the taxi left. She remained at reception where she voiced her anger at the Crisis Team and requested a Complaints Form. | describe it as a note of intent and do not repeat its content. It is not referred to in any witness statements, if is not referred to in the Serious Incident Investigation. | heard it was discussed at the After Action Review but it has not made its way through to the Serious Incident Investigation. It was disclosed to my office on Friday 16 August 2024 and of greater concern the family were not aware of its existence. | am concerned this significant information was not made available much earlier. 2. |.am told the administrative staff do not read complaint forms and it is the process that complaint forms are placed in an envelope without being read or considered and are sent straight to another hospital. However it appears as part of the triage the envelope containing the complaint form is opened at that hospital by a mixture of administrative staff and clinical staff. | am concerned that important information from a patient could be missed and there could also be a significant delay in administering treatment or intervention. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 17 October 2024. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Elise Walsh Deceased. | 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. Date 72/92 [2aone# . C0 eo Andrew Hetherington HM Senior Coroner for Northumberland
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.
Medical Director/Deputy Chief Executive Executive Suite St Nicholas Hospital Jubilee Road NEWCASTLE UPON TYNE NE3 3XT Tel: Mobile: EA: 11th October 2024 Mr Andrew Hetherington HM Senior Coroner for Northumberland County Hall Morpeth Northumberland NE61 2EF Dear Sir Inquest touching the death of Elise Walsh We write to formally respond to your Prevention of Future Deaths (PFD) Report, dated 22 August 2024, following the sad death of Miss Elise Walsh. At the outset we would like to again apologise to you and Elise's family that the existence of the note which Elise wrote prior to her death was not disclosed to your office sooner and did not form part of the Serious Incident Investigation. The note was discussed as part of the After Action Review, which should have then translated into the Serious Incident Report. Unfortunately the Investigating Officer involved in this matter has left the Trust and we have been unable to ascertain why this was not included in the Serious Incident Report. The Trust now carry out internal investigations in accordance with PSIRF (Patient Safety Incident Response Framework). In line with PSIRF CNTW’s review templates have been redesigned to ensure that identified issues / key lines of enquiry are carried forward and are not lost when a review progresses to a full Patient Safety Incident Investigation. Following on from the Inquest the Head of Clinical Risk and Investigations has spoken with the Trusts dedicated Investigating Officers to remind them that whenever an issue is raised as part of discussion during an incident review process it is then explored further and addressed in the completed report. In relation to your concerns around the Trust's complaints process, I can confirm that the Trust have a robust system in place. The Trust has a central complaints team based at St Nicholas Hospital in Gosforth. All complaints are sent here to be logged on a database and triaged centrally. These are opened by trained staff and triaged by senior staff in the Safer Care Directorate. Whilst staff who open the complaints are not clinical, they are trained to review and immediately escalate any concerns to clinicians. Equally at the point of triage, staff are able to escalate any concerns to relevant teams, such as the Crisis Team or Community Treatment Team. Ordinarily complaints received by post are opened and scanned / logged on the system the same day and triaged within 48 hours. Following the Inquest the Trust have added a note to the complaints form that reads, Please be aware your complaint/concern will not be reviewed until it reaches the centralised complaints department. If you need to speak to someone more urgently then please inform a member of staff or call our crisis team on either 111 (selecting option 2) or 0191 814 8899. This change has been communicated to all Trust staff via a CAS (safety) alert. As you heard at the Inquest, owing to confidentiality issues it is unfortunately not possible to implement a process across the Trust, whereby any complaint forms which are handed to receptionists are opened and immediately triaged. Following the inquest this matter has been discussed at the Trust Wide Patient Safety Learning and Improvement Panel (PSLIP) and unfortunately it has not been possible to identify a different system which would allow for such urgent reviews, however the PSLIP panel did request the above addition to the complaints form. As explained at the Inquest, the Trust have however, implemented a system whereby if reception staff have concerns about a patient, they can call for support and a clinician will attend to support the reception staff until such concerns are resolved. If during this period of support the patient writes things down, then clinicians can make a decision as to whether or not it is appropriate to review what they have written, enabling them to act upon the contents if indicated. We hope that the above addressed your concerns. Yours faithfully Medical Director / Deputy Chief Executive 2
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