Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0539, written 10 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 | 10 Oct 2024 |
|---|---|
| Reference | 2024-0539 |
| Deceased | Florence Stewart |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Suicide (from 2015) · Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Central and North West London 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Central North West London NHS Foundation Trust 1 CORONER I am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes 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 26 January 2024 I commenced an investigation into the death of Florence Elizabeth Catherine STEWART aged 27. The investigation concluded at the end of the inquest on 09 October 2024. The conclusion of the inquest was that: Narrative conclusion Narrative conclusion - suicide whilst suffering from mental illness having been admitted as a voluntary patient to the campbell centre milton keynes following her detention under s. 136 of the mental health act, after an incident when she was assaulted on 18th january 2014. 4 CIRCUMSTANCES OF THE DEATH The deceased suffered from mental illness and was admitted to the Campbell Centre in Milton Keynes as a voluntary patient following her detention under S.136 of the Mental Health Act after an incident when she was assaulted om 18th January 2024. When an inpatient she was subject to high level intermittent observations. She but this was unknown to members of staff. The observations were not carried out efficiently and the detection of her hanging was delayed. and suffered a hypoxic brain injury on She hanged herself the 20th January 2024. When found she was attached to a defibrillator the pads were incorrectly placed. She was given oxygen but the oxygen bottle ran out of oxygen during resuscitation. She died at Milton Keynes University Hospital on 23rd January 2024. 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: (brief summary of matters of concern) Firstly that the system of high level intermittent observations failed to prevent Florence's suicide and needs a fundamental review. Secondly, that the Oxygen bottle used during resuscitation ran out of oxygen. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 December 05, 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 I have also sent it to who may find it useful or of interest. 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: 10/10/2024 Tom OSBORNE Senior Coroner for Milton Keynes 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.
Executive Office 2 December 2024 Mr Tom Osborne Senior Coroner for Milton Keynes HM Coroner’s Office Civic Offices 1 Saxon Gate East Central Milton Keynes MK9 3EJ Dear Mr Osborne, Re: Regulation 28: Report to prevent future deaths Thank you for your Regulation 28 report dated 10 October 2024 following the inquest into the death of Florence Elizabeth Catherine Stewart on 23 January 2024. Central and North West London NHS Foundation Trust deeply regrets the death of Ms Stewart and we would very much like to extend our condolences to Ms Stewart’s family and friends. I am writing to provide Central and North West London NHS Foundation Trust (CNWL)’s response to the concerns that you raised in that report. You raised two matters of concern which I will respond to in order: 1. That the system of high-level intermittent observations failed to prevent Florence's suicide and needs a fundamental review. The Divisional Directors have provided assurance that the Campbell Centre management team has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement and have introduced measures to monitor understanding, training, and compliance. They have advised that there have been meetings with all staff to emphasise the importance of adherance to the Policy. The specific themes from Ms Stewart’s inquest have been discussed in group supervision, individual supervision and ward meetings. The Campbell Centre management team has strengthened how temporary and new staff members are inducted to ensure that they can better identify their patients' needs. They have also embedded a system to oversee staff uptake of training in the use of observations and therapeutic engagements. The Nurse in Charge role has been realigned to ensure that the observation system is delivered to prioritise patients requiring high-level intermittent observations and oversee a seamless handover of care when alternating staff members. This includes faster escalation Trust Headquarters, 350 Euston Road, London NW1 3AX www.cnwl.nhs.uk in the event that a patient cannot be immediately located. Observation activity is a standing agenda item in ward safety huddles. The Trust has fully embedded the use of the Brigid app, a hand-held device that allows staff to remain with the patient and enter real-time updates of observation records, automatically updating the Trust's clinical record system. This has been optimised since the inquest and enables staff to document the rationale and frequency of observations, including prompts for random checks. The Campbell Centre management team has refined its governance processes to ensure that changes have been embedded. This includes several checks carried out during each shift by a duty senior nurse to ensure that observations are completed in time, a daily review by the MDT on those patients at most risk of harm, and senior nursing input allocated to support this. A system of audit schedules has been revised to check for weekly improvement, this is led by a senior practice development nurse. The Campbell Centre is part of a Trust-wide Quality improvement project looking to improve patient observation quality. The project commenced in November 2024 and is due to continue until May 2026 2. The Oxygen bottle used during resuscitation ran out of oxygen. The Divisional Directors have confirmed that there is always an ample supply of oxygen across the Campbell Centre, which is easily accessible to trained staff. They have checked that all of our nurses are trained to conduct daily checks of the supplies and that temporary, or new staff members, receive an induction on oxygen availability before they start providing care. The Campbell Centre management team has provided targeted training, including increasing the use of simulation exercises to improve familiarity with oxygen use, in addition to regular mandatory training in emergency life support. Since the inquest, the Trust Resuscitation Group have developed a visual aid that is attached to each oxygen cylinder that clearly explains how to switch on the oxygen. In addition, a written communication highlighting this issue has been sent out to all Trust staff. Thank you for bringing your concerns to our attention. I hope that this response provides some reassurance to both you and Ms Stewart’s family that the Trust takes the concerns raised seriously. Should you have any further questions, please do not hesitate to contact me. Yours sincerely, Chief Executive
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