Source · Prevention of Future Deaths

Neil Challinor-Mooney

Ref: 2021-0164 Date: 20 May 2021 Coroner: Nadia Persaud Area: East London Responses identified: 1 / 1 View PDF

The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation delays and unapparent post-death amendments, compromising their integrity.

Date 20 May 2021

56-day deadline 15 Jul 2021 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

The Inquest heard evidence that the Trust policy in relation to risk assessment and risk management is sufficiently clear; however the Court was not fully satisfied that the policy had been fully embedded into practice. A number of nursing staff, including senior nursing staff, during the course of the admission, failed to follow the policy: Another concern arising during the course of the Inquest related to the integrity of the electronic records. The Inquest heard that medical records should be validated very shortly after entered into the system. The Court saw evidence of multiple entries where there was a significant delay between original entry and validation. Amendments were made to the records after Neil had passed away, but these were not apparent on the records disclosed to the Court. An audit of the records had to be carried out before the amendments were exposed

Responses

1 respondent

North East London NHS Foundation Trust NHS / Health Body

9 Jul 2021 PDF

Action Planned

NELFT has agreed to take a number of actions in addition to actions already taken and provided an action plan detailing the Trust’s efforts to prevent future deaths and to improve the safety and quality of care provided by the Trust. (AI summary)

View full response

Dear Miss Persaud

Re: Inquest touching upon the death of Mr Neil Challinor- Mooney

I refer to your letter dated 20 May 2021 and the Regulation 28 report, detailing your concerns in care provided by NELFT NHS Foundation Trust (‘NELFT’).

We have taken the concerns expressed by you very seriously and agreed to take a number of actions in addition to the actions already taken in respect of learning from the very sad death of Mr Challinor- Mooney. We are very grateful to you for your invaluable contribution in improving patient care.

Please find attached action plan detailing the Trust’s efforts to prevent future deaths and to improve the safety and quality of care provided by the Trust.

I hope that the attached action plan conveys our commitment to continuously improve our services, however if you would like to discuss these actions further, please kindly feel free to contact my office on 0300 555 1201.

Report sections

Investigation and inquest

On the 2gth November 2018 commenced an investigation into the death of Neil Challinor-Mooney, age 51 years_ The investigation concluded at the end of the jury inquest on 12th May 2021. The conclusion of the inquest was that Neil died as a result of suicide contributed to by neglect

Circumstances of the death

Neil Challinor-Mooney suffered an acute relapse in his mental health in late October 2018, He required admission to hospital under provisions of the Mental Health Act on the 1st November 2018. Shortly after his admission to hospital, his trainers were removed from as part of risk management. There was no documentation around the removal of the trainers_ At some_point during the course of admission to hospital Area the him

November to 16th November 2018) Neils trainers were returned to There was no documentation as to when the trainers were returned or any documentation around risk assessment or risk management relating to the decision to return the trainers ;_ On the 13"n November 2018 Neil disclosed in a ward round that he was having suicidal thoughts and that he would use his shoe laces to hang himself. The risk assessment and risk management plan was not updated as a result of this disclosure Neil repeated this disclosure to a junior psychologist on the 14th November 2018. The psychologist disclosed the suicidal ideation and the plan to the senior nursing team_ An action was documented for Neils shoes to be removed; but this was never carried out On the 16th November 2018 Neil was found suspended by the laces of his trainers He was in an unconscious state. Sadly, he passed away at Queens Hospital on the 18th November

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

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Shared signals

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Report details

Reference: 2021-0164
Date of report: 20 May 2021
Coroner: Nadia Persaud
Coroner area: East London

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 2021 (estimated).

Sent to

North East London Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.