Source · Prevention of Future Deaths

Fallon Abby

Ref: 2017-0288 Date: 8 Aug 2017 Coroner: ME Hassell Area: London Inner (North) Responses identified: 1 / 1 View PDF

Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and sharing crucial information, depriving the patient of support upon discharge.

Date 8 Aug 2017

56-day deadline 31 Jan 2018 est.

Responses identified 1 of 1

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)

Coroner's concerns

AI summary

Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and sharing crucial information, depriving the patient of support upon discharge.

View full coroner's concerns

I heard at inquest that no member of the team on Roman Ward contacted Fallon’s social worker. There was no protocol for this.

If they had sought a collateral history from the social worker, they would have discovered that Fallon’s mum was not dead as Fallon had told them, but was alive and living in a hostel. The social worker had been rung by a nurse at the Royal London Hospital, but she was waiting to be invited to a ward round at Mile End Hospital and such invitation was never made.

It seems unlikely that proper discussion with the social worker would have changed the outcome for Fallon, but it would have meant that valuable information would have been shared, and it would have meant that Fallon would have had the benefit of her social worker on hand upon discharge. This might be very important for another patient.

Responses

1 respondent

East London NHS Trust NHS / Health Body

PDF

Action Planned

The Trust's safeguarding children training will include information about the Leaving Care Team, and bespoke training will be provided to ward managers and matrons for cascading to staff. The ward's operational policy will be reviewed to include contacting the Leaving Care Team upon admission of a young person previously in care, and staff will work with the young person to negotiate the involvement of their social worker. (AI summary)

View full response

Dear Madam Inquest touching upon the death of Fallon This is a formal response to your Regulation 28 Report dated 8"h August in which you set out your concerns relating to the care Miss received from East London NHS Foundation Trust. am aware that you heard evidence at the Inquest that Miss Abby had a social worker from the Leaving Care Team. You were concerned that during Miss Abby's admission to the Ward no contact was made with the social worker and no invitation was issued for her to attend the ward round. Miss Abby's case highlighted that there was a lack of knowledge regarding the involvement of the Leaving Care Team, with ward staff unaware that a young adult leaving care would have an allocated social worker up until the age of 25. Therefore , whilst Miss Abby's social worker had been informed of her assessment by the psychiatric liaison team in the Emergency Department she was not contacted by ward staff;, invited to the ward round of informed of her discharge from the ward: In order to address this a number of actions will be undertaken as follows: Firstly, the Named Professional for Safeguarding Children will ensure that Safeguarding Children Training, which is mandatory for all staff, will include information about the Leaving Care Team and their involvement with a young person up to the age of 25. Chief Executive: Dr Navina Evans Abby Abby being

The Named Professional for Safeguarding Children will also undertake some bespoke training with Ward managers and Matrons in relation to this specific issue for cascading to all ward staff. This case and the issues highlighted will also be discussed at the regular Consultant's meeting and again cascaded to junior staff: In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker. With the changes planned you will be content that the Trust has taken these issues seriously and adequately addressed your concerns: If you do require any further information please do not hesitate to contact me_

Report sections

Investigation and inquest

On 19 February 2002, one of my assistant coroners, Heather Williams, commenced an investigation into the death of Fallon Abby, aged 18 years. The investigation concluded at the end of the inquest on 7 August 2017.

I made a determination of suicide, when Fallon jumped from the balcony of her sixth floor bedroom at around 10.45pm on Saturday, 18 February 2017, while two members of the ambulance service were attempting to persuade her to go to hospital for treatment.

Circumstances of the death

Fallon had attended the emergency unit at the Royal London Hospital a week before her death following an intentional overdose, then re-presented with alcohol toxicity. She was admitted to Roman Ward of Mile End Hospital because she was thought to be at high risk of suicide. She was discharged to the care of the home treatment team on Thursday, 16 February 2017.

Copies sent to

Care Quality Commission for England

Similar PFD reports

Shared signals

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Report details

Reference: 2017-0288
Date of report: 8 August 2017
Coroner: ME Hassell
Coroner area: London Inner (North)

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: 31 Jan 2018 (estimated).

Sent to

East London NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.