Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0529, written 4 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Oct 2024 |
|---|---|
| Reference | 2024-0529 |
| Deceased | James Southern |
| Coroner | Sarah Wood |
| Coroner area | Nottingham |
| Category | Alcohol, drug and medication related deaths |
| 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust 1 CORONER I am Miss Sarah Wood, Assistant Coroner, for the coroner area of 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 the 6th of June 2023, I commenced an investigation into the death of James Southern. The investigation concluded at the end of the inquest on the 2nd of October 2024. The conclusion of the inquest was drug related death. 4 CIRCUMSTANCES OF THE DEATH and at the time of death, which was the direct Jimmy died on the 31st of May 2023. He was found unresponsive by his father at his home address in Nottinghamshire. Jimmy suffered with pain and anxiety since his motorbike accident in 2002, and at times in order to cope, was known to self-medicate. There was an elevated reading of cause of death. Jimmy died from a polydrug toxicity. He was receiving care from Nottinghamshire Healthcare Trust following a discharge from Highbury Hospital, Nottingham. However, he wasn’t seen by the services in the months leading up to his death. The investigation and inquest identified there were errors in his records which misled medical practitioners and Jimmy into thinking a care coordinator had been allocated. There was also evidence that the records had not been uploaded in a timely manner and at times after death. There was also evidence that records were amended after death. Jimmy’s case was not transferred to another care coordinator when his care coordinator was absent. This meant Jimmy was left without care in the months leading up to his death. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows – • That there remain potential issues of poor record keeping. • There are concerns over the level of communication between professionals within the Trust and communication with patients. In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you 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 the 29th of November 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. 2. The Nottinghamshire Healthcare NHS Foundation Trust 3. , Jimmy’s mother 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 4th of October 2024 Miss Sarah Wood
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 29th November 2024 Private and Confidential HM Assistant Coroner Sarah Wood Dear Miss Wood Regulation 28 Response: Mr. James Southern I write in response to the inquest which was held 18th and 19th September and concluded on the 2nd October 2024 into the death of Mr James Southern. We accept your findings in relation to the received Regulation 28 and offer sincere apologies to the family of Mr Southern. Please find below the Trust response and actions taken. That there remain potential issues of poor record keeping. We recognise that there were failings in relation to the expected standards of record keeping in the case of Mr James Southern and this fell below the standards expected by Nottinghamshire Healthcare NHS Foundation Trust and regulatory requirements of professional bodies. I would like to assure you that we have taken clear actions in relation to the concerns of individual practice in line with relevant Trust policy including investigating through formal process and referral to professional bodies. We also appreciate that the systems in place need to protect patients from individual errors or omissions and therefore we have also looked at this in the wider context of services and developed some additional clinical quality standards for all staff in relation to record keeping (Appendix A). This information forms part of the current policy in relation to records management and will support staff awareness and personal responsibility. This document along with other similar documents for differing grades and professional backgrounds have been shared with all Care Units within the Trust. In reference to this incident and other incidents, individual accountability is a current focus of development and in collaboration with the Royal College of Nursing the trust is developing bespoke The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA training, for registered and unregistered professionals. Further work that has been completed in relation to ensuring quality and accurate record keeping is the development of specific training for all staff which join the current training programme and compliance overseen for assurance. To provide a continual flow of assurance we have also changed the process and documentation used within mandatory supervision sessions with all clinical staff to include a specific review of the quality of care being provided evidenced within the patient records. Further work is in progress to change the current content of the quarterly patient records audit to be more specific to patients being cared for in the community alongside increasing the frequency of the audit to monthly. The outcome of the audits will then be reviewed and overseen within the Care Unit’s Quality Oversight Group (QOG) and Care Group QOG to ensure senior clinical oversight and assurance. There are concerns over the level of communication between professionals within the Trust and communication with patients. It was deeply concerning to hear the experience of Mr Southern and how the pathway for Mr Southern following his contact with the Crisis Team into the Local Mental Health Team (LMHT) was not properly agreed or communicated between teams, this then led to an avoidable delay which is not acceptable. We have reviewed the pathway between Crisis and LMHT services to ensure that clinical quality standards are in place. There are expected standards that Crisis teams have a clinical conversation with respective LMHT services before discharging a patient from the service. This will ensure that both teams are in agreement to the plan of care required and that this is further communicated to the patient. This standard has been added to the Crisis Team Internal Working Instructions (IWI) and will be further discussed within their local QOG meetings from a wider learning perspective to support learning. Further work relating to place-based interface meetings between teams is currently in progress which will oversee the current process of internal transfers of care, ensure compliance and support wider team communications and closer working relationships to ensure patients receive the standard of care expected. In terms of caseload oversight and allocation there is now an improved process which is incorporated within the LMHT Internal Working Instructions that has been shared and discussed with all teams with further oversight of assurance from weekly oversight meetings, supervision and audits to inform any further potential developments required. I hope that the information contained within this response provides assurance to you and Mr. Southern’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 Chief Nurse The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
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