Source · Prevention of Future Deaths

Martin Baker

Ref: 2018-0130 Date: 3 May 2018 Coroner: Andrew Cox Area: Plymouth, Torbay and South Devon Responses identified: 1 / 1 View PDF

Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric discharge.

Date 3 May 2018

56-day deadline 26 Aug 2018 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric discharge.

View full coroner's concerns

_ (1) It was accepted in evidence that there had been a lack of communication with the family: had not been involved in any psychiatric reviews instead, on one occassion, a consultant was left to rely upon information provided by a junior healthcare assistant: At inquest expressed my view that where a patient has signed a consent form authorising discussion of relevant Derriford Park, Derriford Business Park; Plymouth, PL6 SQZ Tel 01752 204636 Fax The drug fizzy They events with the family, the default position should be that there will be involvement of the family in the absence of any reason not to do SO, for example, a patient's subsequent express instruction not to share something with the family: In this case the family were unaware that Mr Baker had been discharged from psychiatric support and were unaware of what to do in the event of deterioration in Mr Baker's condition: (2) It was also accepted in evidence that at the time of these events there was a shortage of care coordinators something described as "very far from ideal ' was advised that this situation has now been corrected. Nevertheless, it was the clear view of the family, which accepted, that in the absence both of a care coordinator and the involvement of the family there had been no one to act as an advocate on Mr Baker's behalf_something that had been to his detriment.

(3) It was accepted in evidence by that his risk assessment failed to address periodic impulsivity that Mr Baker demonstrated. found this was not causative of the death: Nevertheless , felt this was a point of learning that may well have a bearing in the care of future patients and felt it appropriate to bring it to your attention:

Responses

1 respondent

Bath North East Somerset NHS Trust

PDF

Action Planned

Bath and North East Somerset Council and Avon and Wiltshire Mental Health Partnership NHS Trust have developed a joint action plan to address concerns raised. The plan includes actions, responsible agencies, and timeframes, and incorporates additional learning and monitoring methods. (AI summary)

View full response

Dear Mr Arrow Re: Martin Glyn Baker, DOB 30.03.68 Regulation 28: Report to Prevent Further Deaths In response to the outcome of this case and your Regulation 28 Report to Prevent Further Deaths a meeting was held between senior managers from Bath and North East Somerset Council (the B&NES Council) and Avon and Wiltshire Mental Health Partnership NHS Trust (the AWP Trust) to agree joint approach to address the learning from Mr Baker's death. Within the Bath and North East Somerset local authority area mental health provision is delivered through integrated teams where AWP Trust and B&NES Council staff work alongside each other under a heads of agreement arrangement: However; B&NES Council acknowledges the request within the Regulation 28 Report for the Council to accept responsibility for responding to the recommendations made An action plan to deal with each of the points in the Regulation 28 Report has been prepared by Karyn Yee-King, Principal Mental Health Social Worker for BeNES Council. This details how B&NES Council and AWP Trust will approach each of the points you identified. AWP Trust colleagues have contributed to the drafting of this plan and have agreed the final version: It specifies the actions that we will take in the B&NES local authority area, which agency will take the lead and provides a timeframe for completion of actions 0 CSE H 4 Bath and North East Somerset - The place to Iive work and visit

NS Bath & North East Bath and North East Somerset Somerset Council Clinical Commissioning Group The action plan also incorporates additional learning not documented in the Regulation 28 Report: Finally; the plan also indicates how we will monitor the effectiveness of the changes made Please find a copy of the action plan attached; hope that the actions identified respond Sufficiently robustly to the concerns identified in your report: Please do not hesitate to sontact me regarding any further information you require or if you want a progress update report at a later stage.

Report sections

Investigation and inquest

On 9 September 2016, commenced an investigation into the death of Martin Glyn Baker, then aged 48 investigation concluded at the end of the inquest on 19 April 2018. The conclusion of the inquest was prescription drug-related death: It is likely Mr Baker suffered from a slow metabolism which caused potentially toxic levels of venlafaxine, prescribed to him, to build up Together with a deteriorating physical condition and mild myocardial scarring found at post-mortem, it is likely this induced a fatal cardiac arrhythmia: The medical cause of death was given as Ia) toxicity

Circumstances of the death

Mr Baker suffered with mental health issues for over 20 years. He had previously attempted suicide on a number of occasions. After a failed attempt to take his own life following a jump from height he fractured his spine and was left confined to a wheelchair. Psychiatric support for Mr Baker was provided through Livewell South-west and heard at inquest fromi and both of whom saw the deceased: Prior to the deterioration in Mr Baker s condition that led to his demise_ had decided to stop a prescription of lithium: This was as a consequence of excessive thirst complained about by Mr Baker which, in turn, led to the consumntion pf a large number of drinks and resulted in problems with urinary incontinence was unaware, at the time of his decision_that there had been earlier failed attempts t0 siop the lithium prescribed to Mr Baker_ was also unaware that Mr Baker had signed a form of consent authorising Livewell South-west to discuss care arrangements made_for_him with his family:

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:

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2018-0130
Date of report: 3 May 2018
Coroner: Andrew Cox
Coroner area: Plymouth, Torbay and South Devon

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: 26 Aug 2018 (estimated).

Sent to

Livewell South West

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.