Source · Prevention of Future Deaths

Miriam Stone

Ref: 2024-0277Deceased Date: 20 May 2024 Coroner: Sophie Lomas Area: Derby and Derbyshire Responses identified: 1 / 1 View PDF

Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated by the lack of a formal policy to manage or avoid admissions at these times.

Date 20 May 2024

56-day deadline 15 Jul 2024 est.

Responses identified 1 of 1

Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

Miriam was admitted to the mental health unit at approximately 8.30pm. The unit has a staff handover between 9.00pm and 9.30pm. The evidence at inquest was contradictory as to which shift had assumed responsibility for completing admission tasks including risk assessments and care / safety plans. It was recognised that admission shortly before or during shift handover can increase risks relating to the quality of information sharing and the allocation of admission tasks such as assessing the level of observations required. The court heard evidence that whilst efforts would be made to avoid admission during staff handover time this was a local practice rather than part of any formal policy. The court further heard evidence that senior staff considered that avoidance of admission at handover times would be difficult to achieve because there were too many different oranisations who might be requesting admission. This appeared to overlook the fact that it is the bed allocation team based at the trust who are the central point of contact. The current operational policy covering admission procedures (Acute Inpatient Operational Policy) does not mention a need for handover time to be protected, avoiding admission during this time. Without a formal policy on this topic there is a risk that future deaths could occur.

Responses

1 respondent

Derbyshire Healthcare NHS Foundation Trust NHS / Health Body

17 Jun 2024 PDF

Action Taken

Derbyshire Healthcare NHS Foundation Trust has amended its 'Acute Inpatient Mental Health Services for Adults of Working Age Policy and Procedure' to state that admissions during staff shift handover periods should be avoided where possible, unless there is an urgent requirement related to immediate patient safety. (AI summary)

View full response

Dear Ma’am Re: Regulation 28 Response: an inquest touching the death of Miriam Stone May I first begin on behalf of the Trust by conveying my condolences to the family of Miriam, in particular to for her loss. I was updated following the conclusion of the inquest and am sorry that the Jury found issues with the care afforded to Miriam. I am informed that the Trust confirmed to court on 7 May 2024, following an update from the manager of the bed management team that it was already the custom and practice of the bed management team to not, wherever possible, admit patients during handover times and that this custom and practice was already in operation at the time of the inquest but was due to be placed into the revised policy which had recently been under review. The Trust however acknowledged that due to the presenting risk of a patient it may not always be possible to avoid handover times given the urgent nature of the services the Trust provides. On Wednesday, 8 May 2024 the Trust sent to your office confirmation that the policy which governs the admission to an acute ward, ‘Acute Inpatient Mental Health Services for Adults of Working Age Policy and Procedure’, had been amended to include the line detailed below. That correspondence also confirmed that the updated version had been communicated to the bed management team already but would be formally approved on 6 June 2024. It is best practice for admission during staff shift handover period [7am-7.30 am, 1.45 pm-2.30 pm and 9pm-9.30pm] to be avoided where possible, unless there is an urgent requirement related to immediate patient safety. Learning from incidents has shown that admission during these specific periods leads to an increased risk Trust Headquarters, Ashbourne Centre, Kingsway Hospital, Derby DE22 3LZ

relating to transfer of information or allocation of admission actions. Admission times will be co-ordinated by the bed management team, the referring team, the ward staff and the patient and carers involved. Following the above actions, the formalisation into policy of the custom and practice that already existed has been achieved and I hope that this information reassures you and the family of Miriam that practical steps had already been taken prior to your Regulation 28 Report being sent to the Trust and that the risk you identified has been mitigated against.

Report sections

Investigation and inquest

On 23 February 2022 I commenced an investigation into the death of Miriam STONE aged
41. The investigation concluded at the end of the inquest on 07 May 2024. The medical cause of death was: 1 (a) Hypoxic Brain Injury (b) Cardiac Arrest (c) Ligature Application and Plastic Bag Asphyxia The conclusion of the jury at inquest was a narrative conclusion, namely that: “Miriam carried out the deliberate act of ligating herself on 18th February 2022, but in doing so, it is not possible to ascertain her intention.” The jury found that a lack of formal risk assessment, a safety assessment which did not include all relevant risks and an inadequate care plan were probable contributing factors in Miriam’s death. In addition, the jury found that the level of observations were likely assumed rather than individually assessed and that the level set, namely Level 3 every 15 minutes, was not appropriate.

Circumstances of the death

The circumstances are summarised in the findings of the jury: “ Miriam Stone died on the 20th February 2022 at the Intensive Care unit at the Hospital. Miriam has a history of various mental health disorders including Emotionally Unstable Personality Disorder, Schizoaffective Disorder, Schizophrenia and Bipolar. Miriam was admitted on numerous occasions and had a long history of self-harm by various methods . Miriam was admitted to Hospital on the 15th February 2022 following an overdose. Whilst in hospital, Miriam undertook actions of self-harming and was distressed culminating in Regulation 28 – After Inquest CONTROLLED Document Template Updated 30/07/2021

ligation whilst under 15 minute observations. This resulted in a decision to detain Miriam under Section 2 of the Mental Health Act. Miriam was admitted to the Mental Health Unit on the 17th February 2022 as considered to be a high risk of self-harm or completed suicide and hospital considered a place of safety and assessment. Upon admission Miriam was presenting as calm and not in distress and was being monitored at 15 minute intervals. Miriam was interacting with staff but was not formally assessed by clinical staff and a safety assessment was only partially completed. No documented decision as to levels of observation or suicide risk exists to determine decisions made as to risk. On the morning of the 18th February 2022, 13 minutes after being observed by staff, Miriam was not observable in her bed space and staff recognising the ward toilet door was locked, subsequently found Miriam in the toilet . This was swiftly removed and revealed a ligature around Miriam’s neck .

Miriam was taken to hospital where she was intubated and ventilated. Despite treatment, her condition deteriorated and she died on 20th February 2022.

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Report details

Reference: 2024-0277Deceased
Date of report: 20 May 2024
Coroner: Sophie Lomas
Coroner area: Derby and Derbyshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Jul 2024 (estimated).

Sent to

Derbyshire Healthcare NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.