Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2025-0058, written 12 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Dec 2024 |
|---|---|
| Reference | 2025-0058 |
| Deceased | Huw Erasmus |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Wales prevention of future deaths reports (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 Elysium Healthcare 1 CORONER I am Caroline Saunders, Senior Coroner for the coroner area of Gwent. 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 01 December 2022 I commenced an investigation into the death of Huw Irwin ERASMUS aged 34. The investigation concluded at the end of the inquest on 05 December 2024. The conclusion of the inquest was that: Narrative Conclusion Narrative Conclusion - Huw Irwin Erasmus was at risk of eating vegetation present in the grounds of the Aderyn Unit in Pontypool. Huw died from the toxic effects of consuming a large quantity of Yew leaves in the grounds. Those responsible for his care ought to have known that Yew trees were present, and the leaves were highly toxic and could be fatal if ingested. His death was an accident but it was contributed by a failure of those responsible for his care to identify and manage the risks associated with the ingestion of Yew leaves. 4 CIRCUMSTANCES OF THE DEATH Huw Irwin Erasmus died on 11/11/2022 at Aderyn Unit in Pontypool where he was detained under Section 3 of the Mental Health Act. Huw died from the toxic effects of consuming a large quantity of Yew leaves. Huw did not consume the leaves with the intention of ending his life. 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) Huw was detained at Aderyn Mental Health Hospital from 8/8/2022 to 11/8/2022 under Section 3 of the Mental Health Act. During that time he was granted unescorted leave within the grounds of the hospital. Huw had a propensity to ingest vegetation and it was a condition of his leave that he refrain from so doing. The expectation according to the policy and from staff who gave evidence was that Huw would be assessed following a period of leave. It was also anticipated that this assessment would on occasion include a review of whether Huw had ingested vegetation. Regulation 28 – After Inquest Document Template Updated 30/07/2021 There was no documentary evidence in the clinical records that Huw had been so assessed after a period of unescorted leave. There was also confusion amongst staff about the nature of the assessment and the level of documentation required. Ultimately, the issue was whether in fact these assessments had taken place at all. Although in the circumstances this was not a finding made by the jury, it raises the concern that a failure to understand the requirements of a post-leave assessment and suitably document the findings could result in future deaths. 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 06 February, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family Members Of Huw Erasmus I have also sent it to Health Inspectorate Wales 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: 12/12/2024 Caroline Saunders Senior Coroner for Gwent 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.
Ms Caroline Saunders HM Senior Coroner for Gwent Newport Coroner’s Court 4th February 2025 Dear Ms Saunders Regulation 28 report following the inquest into the death of Huw Erasmus Thank you for your Report dated 12 December 2024. I understand that the concerns to which this Report relates are the requirements for post-leave assessment when a patient has Ground Leave, and the documentation of those assessments. Elysium Healthcare’s Leave (including Section 17) Policy, to which reference was made at the inquest, is that which was current in November 2022. Even before the inquest, Elysium Healthcare had been reviewing this policy and l would like to reassure you that the issues you have raised will be incorporated into this review. The new policy will meet the operational needs of all our units (currently we have over 90). We are looking at a range of issues around leave generally, including issues of risk assessment, documentation and post-leave feedback. The new policy will be adopted and rolled out across all our units. Part of the policy review is to distinguish between leave under Section 17 Mental Health Act and Ground Leave. As you will appreciate, Ground Leave is not Section 17 leave1. Some of the “confusion” to which the Report refers relates to the requirement in the old policy for a “similar” approach for Section 17 leave and Ground Leave. The new policy will ensure there is clear guidance around the process for S17 leave (assessment, documentation and post-leave review) and the process for Ground Leave (assessment, documentation and post-leave review) as distinct entities. In the interim, whilst the new policy is being developed, we have implemented the following changes in respect of Ground Leave at Aderyn: 1. All ward staff have been reminded of the need for the security ‘nurse’ to ascertain that there is no reason for the Ground Leave granted by the Responsible Clinician not to go ahead when they sign a patient out of the unit; 2. Although the Ground Leave is commonly summarised in carenotes (our electronic patient records system) at the end of each shift, all ward staff have been reminded of the need for a record to be made that expressly addresses any issues that have arisen in relation to an episode of Ground Leave, and that they record feedback in relation to any specific conditions of that Ground Leave; 3. The Hospital Director for Aderyn will be auditing a specimen number of carenotes weekly to ensure that these records are being made. 1 See paragraph 27.5 of the Code of Practice to the Mental Health Act: “Except for certain restricted patients (see paragraphs 27.39 – 27.42 and 22.53 – 22.60) no formal procedure is required to allow patients to move within a hospital or its grounds. Such ‘ground leave’ within a hospital may be encouraged or, where necessary, restricted, as part of each patient’s care plan.” Finally, you have raised the issue as to “whether in fact these assessments had taken place at all”. As others may have sight of this response, it is therefore right that I cite the oral evidence that I understand was given at the inquest both by the patient’s Responsible Clinician, Dr Jones, and the Ward Manager, which confirmed that the patient’s Leave was indeed assessed in MDT and other staff meetings. As a result, the patient had had some 84 episodes of Leave at Aderyn without any issues arising in relation to the ingestion of vegetation. This included five episodes of unescorted Ground Leave, which were all the subject of an entry in carenotes providing a comment on the utilisation of that Leave. Yours sincerely Chief Executive
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