Gareth Etchells-Height

Coroner's concerns

AI summary

Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led to fragmented care and a lack of understanding of the patient's condition.

View full coroner's concerns

1. Discharge and safety netting

The discharge report for Gareth did not contain details of his diagnosis or sufficient information about high-risk behaviours/triggers. The information within the discharge report was not fit for purpose and did not provide for an accurate or full handover to new healthcare professionals.

2. Review of the medical notes

There was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth. There was no written guidance on this issue and it lead to Gareth being seen by healthcare professionals who did not have an up-to-date understanding of Gareth’s condition and mental state.

3. Failure to update risk assessment

There was a failure to update Gareth’s risk assessment, which at the date of his death was last updated on 7 April 2022. Gareth’s presentation had materially changed since 7 April 2022, and so the risk assessment effectively became redundant by virtue of the failure to update it. This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours. In evidence it became apparent that the Trust did not have a system in place for routinely checking and updating the risk assessments.

4. Record Keeping

There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth. There is no audit system in place to check the records.

Responses

2 respondents

Sheffield Health and Social Care NHS / Health Body

11 Jan 2024 PDF

Action Planned

Sheffield Health and Social Care NHS Foundation Trust is commissioning a new clinical record keeping policy and training, aiming for completion by May 2024 with training rollout from June 2024, alongside a clinical audit programme. They will also issue a Blue Light Learning Notice to staff regarding timely and accurate record keeping. (AI summary)

View full response

Dear Madam

I am writing in response to the Regulation 28 Report to Prevent Future Deaths received following the inquest touching the death of Mr Gareth Etchells-Height, heard between 10 and 12 October
2023. SHSC is saddened by his death and have taken your concerns very seriously. We are confident we can learn from Gareth’s death and improve the standards of care to mitigate as far as possible, similar circumstances happening again.

Your report raised four matters of concern, namely:

1. Discharge and safety netting

The discharge report for Gareth did not contain details of his diagnosis or sufficient information about high-risk behaviours/triggers. The information within the discharge report was not fit for purpose and did not provide for an accurate or full handover to new healthcare professionals.

2. Review of the medical notes

There was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth. There was no written guidance on this issue and it led to Gareth being seen by healthcare professionals who did not have an up-to- date understanding of Gareth’s condition and mental state.

3. Failure to update risk assessment

There was a failure to update Gareth’s risk assessment, which at the date of his death was last updated on 7 April 2022. Gareth’s presentation had materially changed since 7 April 2022, and so the risk assessment effectively became redundant by virtue of the failure to update it. This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours. In evidence it became apparent that the Trust did not have a system in place for routinely checking and updating the risk assessments.

4. Record Keeping

There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth. There is no audit system in place to check the records.

2

I have outlined below the actions we will take to address each of these matters of concern.

1. Discharge and safety netting

We will complete and audit existing practice in relation to the completion of our discharge summaries and the process and documentation in support of safety netting. We will also review the format and function of our existing discharge templates. These tasks will be completed by the end of February 2024. Any deficiencies identified through these reviews and audits will be used to improve the discharge template in our new Electronic Patient Record System (RIO) and discharge planning practice in our clinical teams.

The new discharge template will be completed by the end of June 2024 and the launch of this will be supported by local best practice training by the Directorate Leadership Team. An audit of quality compliance will be incorporated into the existing cycle of biannual record keeping audits. Results from the audits will be reflected and acted through our local ward governance processes.

The importance of accurate and full completion of the medical discharge summaries will be included in the rotation training programme for medical staff.

2. Review of the medical notes

There is no established local guidance on how to prepare for a clinical review, appointment or handover with practice by and is largely being guided by local custom and practice and training. The Directorate Leadership Team will develop a Standard Operating Procedure covering ‘how to prepare for a clinical review` which will include what documentation should be read as part of the preparation for this by 30 April 2024.

On completion, the guide will be disseminated through local governance structures, via supervision and training arrangements to all clinical staff who utilise our electronic patient records and be available on our intranet.

3. Failure to update risk assessment

The individual practitioners involved in the review of care are aware of the importance of reviewing and updating risk assessments for individual clients. As we move to our new electronic patient record, this will give us opportunity to set review requirements as an automated reminder in addition to individual clinical judgement. This will be the Trust system to flagging the need for review of risk assessment documentation.

Our training currently focuses on the importance of reviewing and updating risk assessments, we will continue to deliver these key messages through supervision and monitor through clinical audit, recognising that clinical audit is a snapshot of overall caseloads. Audit will also take place through individual clinical supervision at team level as part of the record keeping requirements.

We will request regular reporting on clinical record keeping audits and monitor progress via our Directorate Leadership Teams into the Clinical Quality and Safety Group.

4. Record Keeping

I will refer back to my letter dated 3 November 2023 where we outlined the move to our new record system (RIO). The implementation of the system has been delayed for some services in the Trust, however, the functionality of RIO will bring about significant automated improvements in record keeping.

3

In addition to the positive impact of the electronic record implementation this year, we have also commissioned a new clinical record keeping policy and training, which aligned to the quality improvement programme we noted in our letter (3 November), will be rolled out to all staff teams. Built alongside this will be a robust audit programme which will include Trustwide clinical audit and team level audits through supervision and spot check audits as part of our Quality Assurance programme. We anticipate the policy will be completed by May 2024 and the training will commence roll out, alongside a clear communication plan from June 2024.

In the meantime, we will issue a Blue Light Learning Notice to all clinical teams and flag through our Trustwide cascade with the Executive Team the need to record accurately all patient facing interactions in a timely manner.

I trust that this addresses the issues raised to your satisfaction. These actions will be monitored and reported to the Executive Team and Trust Board. Please do not hesitate to contact us if you require any additional information regarding our actions.

May I again extend my sincere condolences to Mr Etchells-Height’s family.

Sheffield Health and Social Care Update NHS / Health Body

27 Jun 2024 PDF

Action Taken

Sheffield Health & Social Care NHS Foundation Trust has implemented several changes including instructing Responsible Clinicians to capture diagnoses in the electronic patient record, reviewing the format of discharge summaries, implementing a tool to support clinicians in using patient records, and rolling out a new clinical record keeping training package. (AI summary)

View full response

Dear Madam

I am writing in response to the Regulation 28 Report to Prevent Future Deaths received following the inquest touching the death of Mr Gareth Etchells-Height, heard between 10 and 12 October 2023. Following my last letter to you dated 11 January 2024, you requested an update be provided outlining the progress of our actions by 30 June 2024. This letter seeks to provide that update.

1. Discharge and safety netting

You were concerned that the discharge report for Gareth did not contain details of his diagnosis or sufficient information about high-risk behaviours/triggers; that the information within it was not fit for purpose and did not provide for an accurate or full handover to new healthcare professionals.

The Clinical Director for Acute and Community Services has provided instruction via email to all inpatient Responsible Clinicians that diagnoses must be captured in Insight (our electronic patient record system) to enable them to be pulled through onto the discharge summary. Discussions have taken place regarding the purpose of discharge summaries and the misunderstanding of their use. We commissioned 360 Assurance, our internal auditors, to undertake an audit of our clinical record keeping, including risk assessments and discharge summaries. This audit was completed in May 2024. From the findings of the audit and the new national guidance that was issued in January 2024, we have agreed to review the format and function of our discharge summaries to include early warning signs of deterioration. The revised format will be incorporated as we rollout our new electronic patient record system (Rio) in late 2024/early 2025.

2. Review of the medical notes

You told us that there was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth and that there was no written guidance on this issue, which lead to Gareth being seen by healthcare professionals who did not have an up-to-date understanding of his condition and mental state.

We developed a clinical record keeping standards policy earlier this year to provide clarity on the expected requirements to ensure high quality, person centred clinical documentation across the Trust. Incorporated within this is a section to guide clinicians around preparing for service user appointments, ensuring they are briefed on the current issues, risks and concerns. It is accepted that this will depend upon the relationship between the service user and their worker. This will enable staff to have an up-to-date understanding of the service user’s condition and mental state.

3. Failure to update risk assessment

You reported that there was a failure to update Gareth’s risk assessment, which at the date of his death was last updated on 7 April 2022. Gareth’s presentation had materially changed since 7 April 2022, and so the risk assessment effectively became redundant by virtue of the failure to update it. This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours. In evidence it became apparent to you that the Trust did not have a system in place for routinely checking and updating the risk assessments.

Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update. We are currently considering the feasibility of developing these dashboards for other services. The internal audit of record keeping highlighted the need to ensure that the ‘clinical risk and management of harm policy’ has a clear governance route for reviewing audits of compliance for risk assessments, which will take place biannually across the Trust. A formal report will be presented biannually on progress with clinical record keeping and clinical risk assessment improvements to the Quality Assurance Committee, a sub-committee of the Board of Directors. In addition, as part of the new electronic patient record development, key clinical leaders will be scoping the development of a new clinical risk assessment tool.

4. Record Keeping

You recorded a failure generally to keep proper records. It became clear to you as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth and you were concerned there was no audit system in place to check the records.

All staff have been reminded about the importance of good quality record keeping through an alert cascade that was produced, disseminated and published on the staff intranet.

Following the publication of the new clinical record keeping standards policy, a new training package has been developed to support the implementation of the policy and a pilot training session has already taken place with preceptee nurses. The feedback from this pilot session has been extremely positive. The training is now being rolled out across the Trust by the Clinical Risk and Patient Safety Advisor.

I trust that this provides the necessary assurance on our progress with the Regulation 28 Report. Please do not hesitate to contact me if you require any additional information.

May I again extend my sincere condolences to Mr Etchells-Height’s family.

Report sections

Investigation and inquest

On 20 September 2022 an investigation was commences into the death of Gareth Etchells-Height born on 13 July 1979. The investigation concluded at the end of the inquest on 10 October 2023. The conclusion of the inquest was a narrative one and read:-

Following a deterioration in his mental health, Gareth Micheal Etchells-Heights died at the Wainwright Centre, 48 Wainwright Crescent, Sheffield, where he was found by support staff with a ligature Gareth intended to take his own life. There were various missed opportunities during Gareth’s care, and his death was contributed to by a missed opportunity to communicate to him that he would not be discharged from the Wainwright Centre on 25 April 2022. The cause of death was:

(1)(a) Asphyxiation by ligature

Circumstances of the death

In January 2022, Gareth’s mental health began to deteriorate culminating in an incident on 17 February 2022 when he was attended up by the British Transport Police at Sheffield Train Station and placed on a s.136, meaning that he was removed from the train station to a place of safety at the Longley Centre in Sheffield.

Gareth was then subject to an assessment under the Mental Health Act between 23:05 hours on 17/02/2022 and 03:15 hours on 18/02/2022. During this assessment, Gareth was presenting with symptoms of psychosis, including delusional and persecutory thoughts.

The assessment that was made of Gareth was that it was unclear whether the psychosis was long standing, or drug induced, and that Gareth was at risk of death by misadventure or retaliatory action.

In circumstances where there was a query about whether the psychosis was drug induced, that “usual practice would be to monitor for 2 -3 days if drug induced psychosis”; this was not done on 18/02/2022.

Gareth stayed for the remainder of the morning in the s.136 suite at the Longley Centre before leaving at approximately 11:30 hours. At approximately 14:30 Gareth phone HTT worried about his own safety. By 16:16 hours on 18/02/2022, the police had re-referred Gareth for assessment at the Longley Centre using their s.136 powers. He was then re-assessed between 14:00 and 19:45 hrs on 19/02/2022.

The view that was taken by the assessing team was that Gareth’s paranoid beliefs had progressed to identifying individuals colluding against him and that his “presentation was markedly different” to the previous assessment. It was assessed that the risk of “significant self-harm was very high and … that the only option was to admit to hospital under s.2 of the MHA.”

Gareth was then admitted to Maple Ward on 19 February 2022 and remained an inpatient until 22nd March 2022, when he was moved to a step-down bed at Wainwright Crescent. It should be noted that Gareth’s section expired on 18th March 2022, and so he remained for the final few days as a voluntary inpatient.

Sadly, Gareth’s condition continued to deteriorate until in the early hours of the morning on 24 April 2022, he tied a ligature at Wainwright Crescent Before Gareth died, he wrote a collection of notes were referred to as suicide notes.

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