Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0645, written 25 Nov 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 Nov 2024 |
|---|---|
| Reference | 2024-0645 |
| Deceased | Jaipreet Panesar |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Community health care and emergency services related deaths · Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Oxford Health 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 before an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive, Oxford Health NHS Foundation Trust 1 CORONER I am HEIDI J CONNOR, Senior Coroner for Berkshire for the coroner area of Berkshire 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. It is important to note the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London. This case clarifies that the issuing and receipt of a Regulation 28 report entails no more than the coroner bringing some information regarding a public safety concern to the attention of the recipient. The report is not punitive in nature and engages no civil or criminal right or obligation on the part of the recipient, other than the obligation to respond to the report in writing within 56 days. 3 INVESTIGATION The family requested me to refer to the deceased as Jai. I will reflect that in this report. I conducted an inquest into the death of Jai which concluded on 21st of November 2024. I recorded a conclusion of suicide. 4 CIRCUMSTANCES OF THE DEATH Jai was a 36 year old GP. She was found deceased on 27th of April 2023. I have not detailed all of Jai’s contact with mental health services in this report. Instead, I have focused on aspects of the chronology which are relevant to the concerns I am raising. Jai referred herself to the Crisis Response and Home Treatment Team (“the crisis team”) on 21st of June 2022. She attended three appointments in June and July 2022, and was discharged from the crisis team to Buckinghamshire Talking Therapies (“BTT”) Regulation 28 – Before Inquest Document Template Updated 30/07/2020 on 29th of July 2022. Whilst under this team, Jai disclosed that she had made previous suicide attempts. From August 2022 onwards, the mental health support that Jai received was from teams other than BTT. These teams used a different electronic records system (called Rio). They are part of the same NHS trust, but it was not possible for clinicians to access both systems. After an attempt to refer Jai to the crisis team (by her GP) on 31st of August 2022, Jai was provided with an appointment date with the community mental health team. The appointment date was 8th of September 2022. Before that appointment could happen, Jai attended accident and emergency (after being encouraged to do so by friends and her GP). She was then admitted as a voluntary patient to a psychiatric ward, until 7th of September 2022. After she was discharged, Jai was under the crisis team for around 10 days. After that, no medium or long term plan was put in place, and she was discharged back to the care of her GP. Jai took her own life in April 2023. She was not under secondary mental health services at the time of her death. 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: 1. The Trust’s own internal investigation highlighted the fact that no care co- ordinator or key worker was provided to Jai after her discharge from hospital on 7th of September 2022. The Trust’s initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from Jai’s death. It is still not possible for teams using RiO and the BTT systems to access each other’s clinical notes. 2. 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. Regulation 28 – Before Inquest Document Template Updated 30/07/2020 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 20, 2025. 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 Jai’s family, via their legal representative. I have also sent this report to the following recipients who have an interest in this matter: 1. NHS England – I consider that these issues are likely to be national rather than only local; 2. Legal representative for the GP practice involved in this case; and 3. , Senior Coroner for Buckinghamshire, as a matter of courtesy. who may find it useful or of interest. I 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. 9 Dated: 25/11/2024 HEIDI J CONNOR Senior Coroner for Berkshire for Berkshire Regulation 28 – Before Inquest Document Template Updated 30/07/2020
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.
Private & Confidential Heidi J Connor Senior Coroner for Berkshire Sent via email only to Chief Executive’s Office Trust Headquarters Littlemore Mental Health Centre Sandford Road Littlemore Oxford OX4 4XN 13 January 2025 Dear Senior Coroner Connor, Inquest into the death of Dr Jaipreet Panesar Report on Action to Prevent Future Deaths Response of Oxford Health NHS Foundation Trust Thank you for your letter of 25th November 2024 following your conclusion into the tragic death of Dr Panesar. I write to respond to your concerns. The matters of concern that you identified are – 1. The Trust’s own internal investigation highlighted the fact that no care coordinator or key worker was provided to Jai after her discharge from hospital on 7th of September 2022. The Trust’s initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from Jai’s death. 2. It is still not possible for teams using RiO and the BTT systems to access each other’s clinical notes. I understand that the Trust provided you with some documentation at the inquest relating to these issues, in particular a statement made by the team manager of the Trust’s Chiltern Crisis Resolution & Home Treatment team, a statement made by the Head of Inpatient Services for Buckinghamshire, an email from the Deputy Clinical Lead of Buckinghamshire Talking Therapies (BTT) and a copy of BTT’s standard operating procedure. In relation to your first concern, I acknowledge that a delay in the completion of an action that arises from a patient safety incident investigation is a concern. I have asked to receive a report from the Oxford Healthcare Improvement Manager by the end of January 2025. In the meantime, I am satisfied that the Quality Improvement project has been progressing well. The purpose of this project is for us to ensure that the changes made are sustainable and Trust wide and that they do indeed mitigate against the risk of a similar event. I have been informed that a meeting takes place every fortnight in order to review progress (the most recent meeting was on 17th December 2024). The Trust is clear about the critical importance of the process by which a patient’s care is transferred from a ward to community teams. It is a process that will always remain under scrutiny by Trust governance and audit. I understand that your second concern relates to records held by Buckinghamshire Talking Therapies (BTT). It was the case that members of our secondary care services did not have access to those records in 2022 and 2023. That remains the case, in that staff in secondary care services cannot log into BTT’s electronic records system direct. The position is that secondary care services have access to a system called Thames Valley & Surrey (TVS) Shared Care Records/Graphnet, to which system BTT has uploaded patient information dating back to 1st May 2022. This upload concluded in November 2024. Subsequently, all patients accessing BTT will have information of their involvement with BTT uploaded on TVS each day (unless they have universally opted out of information sharing). More generally, our Intranet contains guidance on the use of Thames Valley & Surrey Shared Care Records and this guidance was most recently updated on 12th December 2024. For their part, some BTT staff have direct access to RiO, which is the electronic health records system used by the Trust’s secondary care services. Those staff include the admin team, referral co-ordinators in SPA, and supervisors. BTT’s standard operating procedure records the procedure for BTT staff to do so. I understand that you have received a copy of that operating procedure. I am satisfied that BTT’s access to RiO is established and effective for their purposes. I hope that this response provides you with the information that you require, but of course please do not hesitate to contact me if I can assist further. Yours sincerely, Chief Executive 2
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