Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0646, written 26 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 | 26 Nov 2024 |
|---|---|
| Reference | 2024-0646 |
| Deceased | Emma Sanders |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive of NHS England 2. The Chief Executive of NHS Dorset 1 CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset. 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 4th April 2023, an investigation was commenced into the death of Emma Victoria Sanders, aged 34 years. The investigation concluded at the end of the Inquest on the 18th November 2024. The medical cause of death was: Ia Hypoxic Brain Encephalopathy Ib Asphyxia The conclusion of the Inquest was a narrative conclusion that Emma Victoria Sanders died as a consequence of the self-application of a ligature to her neck, in circumstances where her intention remains unclear. 4 CIRCUMSTANCES OF THE DEATH Emma had a complex mental health history with confirmed diagnoses of Emotionally Unstable Personality Disorder (EUPD) and complex Post Traumatic Stress Disorder (PTSD) and was known to regularly self harm by a variety of means. Emma had a history of opiate dependence and on the 22nd February 2023, she began a period in a detoxification and rehabilitation placement in Cornwall in order to become abstinent from methadone so she could progress to therapy treatment for her mental health diagnoses. Prior to this she had experienced a period of relative stability with her mental health. During this placement the methadone prescription was reduced more quickly than she had experienced before, and she became emotionally dysregulated. Her mental health deteriorated, and her acts of self harm increased as a result of which she 1 was taken to the local hospital in Cornwall. The placement was ended on the 7th March as it was felt her risks were too high to be managed in that setting. On the 14th March 2023 Emma was taken to the Emergency Department at the Royal Bournemouth Hospital, Bournemouth after she disclosed that she had taken an overdose of her prescribed medication. At this time the hospital was experiencing extreme capacity pressures and Emma was placed in the cohorting corridor which was being staffed by paramedics due to the capacity pressures. At 18.58 hours, when for a very short period of time there were no staff in the corridor, Emma can be seen on the CCTV of the corridor to secret upon her person a nasal canula with plastic tubing from an equipment trolley. At 19.53 hours Emma went to the toilet in the Emergency Department. At 20.03 hours, Emma was found in a collapsed and unresponsive condition on the floor of the toilet with a ligature fashioned from nasal canula tubing around her neck. Following attempts at cardiopulmonary resuscitation there was a return of spontaneous circulation, and she was admitted to the critical care unit at the hospital where she continued to receive care, however her condition deteriorated, and she died on the 19th March 2023. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters 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 MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. At the time of her death Emma had a Frequent Attender Care plan, or as they are now known a High Intensity Use Care Plan, in place. This plan was agreed by representatives from Dorset Healthcare NHS Foundation Trust (DHUFT) who provide the mental health care across Dorset, a representative from the Royal Bournemouth Hospital, a representative from Poole Hospital and a representative from We Are With You (WAWY) who supported Emma with her substance misuse. The aims of this plan for Emma were: • to provide a consistent approach when Emma presented to the emergency department • to streamline her care so that she does not have to wait any longer than necessary in the ED as she has identified this makes her feel worse • to minimise the impact on emergency department resources when Emma attends • to reduce the use of restrictive interventions which may exacerbate Emma’s distress ii. South West Ambulance Service NHS Foundation Trust (SWAST), who provide the paramedic care in the South West, were not provided with the plan prior to the 14th March 2023, nor were other hospitals Emma may present to, such as the other local hospital in Dorset, Dorset County Hospital, or the hospital in 2 Cornwall where Emma was taken to when she self harmed on the 5th March 2023 during her time at the detoxification and rehabilitation placement. iii. On the 14th March 2023, due to the capacity issues the cohorting area was opened at the Royal Bournemouth Hospital and representatives from SWAST were caring for the patients in the cohorting area. When Emma arrived at the hospital, she was taken to the cohorting area and was booked into the hospital by the triage nurse from the hospital, although was not seen by them and her previous records were not accessed. iv. There can be a delay in accessing the hospital patient record when a patient arrives at the hospital as following the booking in process, there needs to be a merger of the ambulance paperwork to verify they have the correct person before the hospital patient record can be accessed. The process adopted by different hospitals may cause a delay in access to the hospital patient record and evidence was given that at the Royal Bournemouth Hospital this could be anything up to 10 minutes from experience. v. When Emma arrived at the hospital she was booked in by the triage nurse between 18.49 and 18.52 hours, however the merger of her records did not happen until 18.59 hours. No representative from the hospital saw Emma prior to her death and she was monitored by the SWAST paramedics in the cohorting area, so there was no access to her patient record which detailed her significant history of self harm and the Frequent Attender Care Plan. The Frequent Attender Care Plan was not followed throughout the 1 hour and 47 minutes Emma was with professionals from when SWAST attended her home address until the time she was last seen prior to her death. Had it been accessed, and there would have been opportunities to discuss with Emma further support for her whilst she was at the hospital and the evidence given by the witnesses who had contact with her that day was that they would have considered managing her care differently. followed, vi. University Hospitals Dorset NHS Foundation Trust, of which the Royal Bournemouth Hospital forms part, have taken action internally to ensure that a person’s records are now available when a person arrives at the hospital and this would include access to Frequent Attender Care Plans, however evidence was given that a similar process around the merger of records is undertaken at other hospitals across the South West, from the experience of SWAST, and this may also be a national issue. vii. The Summary Care Record (SCR) is accessible to a variety of healthcare professionals and accessible to SWAST. 3 viii. As per the NHS England website, link found here Summary Care Record - NHS England Digital, “The Summary Care Record (SCR) is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care”. ix. Documents cannot be uploaded to the SCR, however a section can be added to the SCR to detail information such as care plans. Evidence was given that the content of the SCR is controlled by the specific Integrated Care Boards (ICB) covering that area. There are 42 ICBs across England and Wales. x. The SCR for Dorset does not include a section to detail the care plans in place for individuals. The Deputy Director for Care for SWAST gave evidence that none of the ICBs in the South West Region has a section in the SCR to detail care plans in place for individuals. IF there were such a section, the GP of the individual would then be responsible for uploading the details to the SCR and then it would be accessible to other health professionals the person comes into contact with nationally. 2. I have concerns with regard to the following: i. ii. There can be a delay in accessing a patient’s hospital record and history when they are taken to hospital by a paramedic depending on the method of booking in and triage which could impact on patient care, especially if there are delays in them being assessed such as when they are placed in cohorting areas, and this could lead to a future death. The Summary Care Record does not detail care plans in place for individuals in Dorset, the wider South West region and may be nationally. Lack of access to these plans could impact on patient care and lead to a future death. 6 ACTION SHOULD BE TAKEN In my opinion urgent 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, 21st January 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. 4 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Emma’s family (2) Dorset Healthcare University NHS Foundation Trust (3) University Hospitals Dorset NHS Foundation Trust (4) South West Ambulance Service NHS Foundation Trust (5) We Are With You I am also under a duty to send the Chief Coroner a copy of your response. I have also sent a copy of this report to the following persons for their awareness: a) BCP Council, as they were involved in the Inquest b) Chief Executive of Dorset County Hospital, Dorset c) , Service Manager, St Mungo’s 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 Signed 26th November 2024 Rachael C Griffin 5
2 responses 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.
21 January 2025 Mrs R C Griffin Senior Coroner The Coroner’s Office for the County of Dorset Town Hall Bournemouth BH2 6DY Sent via email: Dear Mrs R C Griffin Vespasian House Barrack Road Dorchester DT1 1TG Tel: Re: Regulation 28 Report to Prevent Future Deaths (ref 30595408) I am writing to you in response to the concerns raised by your investigation into the circumstances surrounding the tragic death of Emma Victoria Sanders. We take our responsibility to act on the learning from serious incidents seriously and I offer you this response to outline where NHS Dorset can use its role to support and influence some of the changes you seek. 1. As per Paragraph 2 (i/ii) of your report outlining your concerns, a review has taken place on the process of identification of patients with High Intensity Care Plans. The uploading of patient records into the national summary care record remains an issue and is out of the control of NHS Dorset. However, we will enforce the use of the Dorset Care Record in line with our contractual commitments in 2025/2026 and onwards. 2. In addition, we will monitor progress of the issue directly via our Corporate Risk Register. This will have Board level scrutiny. 3. The Regulation 28 Report will be shared and reviewed with NHS partners and wider system partners at the Pan Dorset Mortality Group. I hope that the information I have offered provides some assurance that the findings of your investigation and the areas you have highlighted for the prevention of future deaths has prompted action and remains the focus of our continued commitment to supporting the safety and wellbeing of everyone who uses NHS services. Yours sincerely Chief Executive Officer NHS Dorset
Ms Rachael Clare Griffin
HM Senior Coroner
Coroner’s Office for the County of Dorset
BCP Civic Centre
Bourne Avenue
Bournemouth
BH2 6DY
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
22 January 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Emma Victoria Sanders
who died on 19 March 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26
November 2024 concerning the death of Emma Victoria Sanders on 19 March 2023.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Emma’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Emma’s
care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Emma’s family or friends. I realise that
responses to Coroner Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
Your Report raised concerns over delays in accessing a patient’s hospital record and
history when they are taken to hospital by a paramedic, depending on the method of
booking in and triage, and that the Summary Care Record does not detail care plans
in place for individuals in Dorset, the wider South West region and possibly nationally.
The Royal College of Emergency Medicine
(RCEM) have developed
guidance that addresses case management of frequent attendance in the Emergency
Department, including multi-agency care plans. The guidance can be found here:
Frequent_Attendance_in_the_Emergency_Department_v1.pdf
The Summary Care Record (SCR) is a national database that holds electronic records
of important patient information such as current medication, allergies and details of
any previous bad reactions to medicines. It is created from GP medical records so
whenever a GP record is updated, the changes are synchronised to the SCR. It can
be seen and used by authorised staff in other areas of the health and care system who
are involved in the patient's direct care, but do not need access to the patient's full
record. As such, the SCR is intended to provide a summary of the patient’s GP record,
including the key information most likely to be of benefit to patients during an
unscheduled care encounter.
The SCR can include more detailed information in addition to the patient’s current
medication, allergies and reactions to medicines, which is referred to as ‘Additional
Information’. This Additional Information may include significant medical history,
anticipatory care information (such as information about the management of long-term
conditions), immunisations or specific communications needs. This information is now
included by default for patients with an SCR, unless they have previously told the NHS
that they did not want this information to be shared. It can also include any history of
deliberate self-harm, suicide attempts or suicidal ideation.
The SCR is not intended to include the full detail of a patient’s care plan, and the
design / format of the SCR does not support this. However, the SCR can include a
signpost to the existence of a care plan by using a relevant code for the following, or
otherwise a free-text entry:
• Emergency health care plan
• Liaison psychiatry care plan
• Mental health crisis plan
• Crisis plan
• Treatment escalation plan
• Community mental health care plan
The SCR content is only authored from the patient’s registered GP Practice. For
information about the existence of a care plan to be shared in this way, the patient’s
GP Practice needs to be made aware of the care plan and then enter this information
using an appropriate specific clinical code.
With regards to the SCR, at present, approximately 88.1% of the population have a
Summary Care Record with Additional Information, 7.3% have a Core Only SCR
(Allergies and Medications only) and 1.5% have opted out of having a SCR.
Furthermore, where possible, patients need to provide their ‘Permission to View’
before their SCR can be accessed. However, an Emergency Access option is
available for scenarios where a patient is not able to provide their ‘Permission to View’
e.g. the patient is unconscious.
Additional to the SCR, NHS England’s National Record Locator (NRL) service allows
health or social care workers to find and access patient information shared by other
health and social care organisations across England, to support the direct care of a
patient. It does this by recording the location of digital (and paper) records within the
NHS and providing an index of pointers/bookmarks that contain the information
required to retrieve key patient information from the source.
The NRL removes the need for organisations to create duplicate copies of information
across systems and organisations, by facilitating access to up-to-date information
directly from the source. It also provides users with an indication of the organisations
with which a patient currently has a care relationship, to enable a user to contact the
service responsible for a plan to support the individual in the event of a crisis.
It is important to note that the author of NRL documents is the creator of the document
(e.g. a Mental Health Trust), whereas the author of the SCR is the patient’s registered
GP Practice. Mental Health Crisis plans are one of the pointer types supported by the
NRL Service. NRL does not store any of the Mental Health data, but points users to
where they can find it. NRL Information can be consumed from source through the
National Care Records Service (NCRS).
The NCRS is an additional service that allows health and social care professionals to
access and update a range of patient and safeguarding information, which is available
across regional Integrated Care System (ICS) boundaries. The service provides a
summary of health and care information for care settings where the full patient record
is not required to support their direct care.
The services available in NCRS include the Summary Care Record and the National
Record Locator. A full list of services is available here:
https://digital.nhs.uk/services/national-care-records-service#what-we-deliver
In addition, the Connecting Care Records (ConCR) programme, previously known as
the Shared Care Record programme, could also be used to share these care plans.
The NCRS complements ConCR which is a way of bringing separate records from
different health and care organisations together digitally in one place and joining up
information based on an individual rather than one organisation. ConCR can include
care plans and will typically hold more information about an individual than a Summary
Care Record.
Responsibility for delivering shared care records sits with local Integrated Care Boards
(ICBs). Each ICB’s shared care records are developed in response to the health and
care needs of the local area, existing systems, and future planning. This means some
of their shared care records are available to neighbouring ICBs, while others are only
supported within their own ICB.
A number of Mental Health Trusts (currently 15 out of the 50 in England) also provide
access to their patients’ Crisis Plans via the National Record Locator (NRL). When
trusts choose to share their patients’ information, their Electronic Patient Record (EPR)
system automatically creates a “pointer” on the NRL, which tells another clinician (such
as a Paramedic) that a record exists. Most of the trusts connected to the NRL also
allow a real-time pdf of the care plan document itself to be retrieved by the clinician.
NHS England understands that Dorset Healthcare University NHS Foundation Trust
does not currently share their crisis plans through the NRL, although their EPR system
supplier are accredited to connect to it. However, to our knowledge, the South Western
Ambulance Service does use NCRS and NRL widely and would be able to receive it.
We refer the Coroner to the response from the Chief Executive of NHS Dorset for
further information on local and regional arrangements.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Emma, are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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