Devon Partnership Trust Care
NHS / Health Body
Action Taken
Devon Partnership Trust has shared the coroner's findings with relevant services and completed the action plan developed in response to a Serious Incident Investigation following the death. Actions taken address how risk assessment information is recorded and shared. (AI summary)
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Dear Ms Longhorn
Re: Archi Johnson - Inquest 11 May 2022 Regulation 28 Report to Prevent Future Deaths
Thank you for your letter following the inquest into the death of Archi Johnson. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust.
The Trust has undertaken a Serious Incident Investigation following the death of Archi; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.
Your report contained the following matters of concern -
1) Evidence was heard regarding the manner in which information crucial to the formulation of risk assessments was recorded and shared:
a) Two types of risk assessment were completed, with no system to ensure that important information is present in both
b) The previous incident in which Archi had attempted to his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by the staff and therefore not known to a number of those responsible for his care
c) Those responsible for his care accepted that the above incident was one which they would have wanted to have knowledge
d) The absence of that information may have affected the subsequent decisions made regarding the setting of risk level, observation level and removal of potentially dangerous ligature items
We have attached a copy of the actions we have taken or continue to progress to ensure that lessons are learnt from this tragic death. I hope that the actions described demonstrate our commitment to the learning we have undertaken and that the Trust is committed to this
continued positive work within our services. If you require any further information please do not hesitate to contact me.
As you may be aware, the Trust is currently experiencing issues accessing our usual electronic patient record systems and as a result there may be some delays in completing the actions relating to the clinical audit as this will depend on our being able to access the full clinical records. We continue to support people who use our services and the Trust is able to maintain current records using a secure alternative. We are working closely with the software provider to resolve these technical issues and apologise for any delay that may result.
Re: Archi Johnson - Inquest 11 May 2022 Regulation 28 Report to Prevent Future Deaths
Thank you for your letter following the inquest into the death of Archi Johnson. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust.
The Trust has undertaken a Serious Incident Investigation following the death of Archi; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.
Your report contained the following matters of concern -
1) Evidence was heard regarding the manner in which information crucial to the formulation of risk assessments was recorded and shared:
a) Two types of risk assessment were completed, with no system to ensure that important information is present in both
b) The previous incident in which Archi had attempted to his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by the staff and therefore not known to a number of those responsible for his care
c) Those responsible for his care accepted that the above incident was one which they would have wanted to have knowledge
d) The absence of that information may have affected the subsequent decisions made regarding the setting of risk level, observation level and removal of potentially dangerous ligature items
We have attached a copy of the actions we have taken or continue to progress to ensure that lessons are learnt from this tragic death. I hope that the actions described demonstrate our commitment to the learning we have undertaken and that the Trust is committed to this
continued positive work within our services. If you require any further information please do not hesitate to contact me.
As you may be aware, the Trust is currently experiencing issues accessing our usual electronic patient record systems and as a result there may be some delays in completing the actions relating to the clinical audit as this will depend on our being able to access the full clinical records. We continue to support people who use our services and the Trust is able to maintain current records using a secure alternative. We are working closely with the software provider to resolve these technical issues and apologise for any delay that may result.