Source · Prevention of Future Deaths

Matthew Roberts

Ref: 2017-0028 Date: 9 Feb 2017 Coroner: Bridget Dolan QC Area: West Sussex Responses identified: 1 / 1 View PDF

There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk assessment. The organization also failed to conduct a formal review of the death.

Date 9 Feb 2017

56-day deadline 23 Apr 2017 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken: : That there was no relevant policy, procedure or practice requiring faxes to the Bognor EI team be logged and scrutinised on receipt so that it might noted if faxed pages were and potentially important information not received. That there was no policy, procedure O1 practice, requiring member of the EI team t0 read written information provided by a referrer before the and initial risk assessment: Additionally it was practice, on occasions for the information to be left unread until shortly before the first face to first appointment with the patient: Hence the determination of patient's needs, the current level of risk and the urgency with which the first contact should be made with a was not informed by all the available information fully considered. That there was no relevant policy, procedure Or practice whereby the Bognor EI team would clearly confirm with the referrer the date on which contact with newly referred would be made That SPFT did not appear to have undertaken any formal review of the death of someone known t0 the organisation and, although SPFT were aware a RCA was conducted by Avon and Wiltshire NHS Trust; SPFT had not received nor sought that final RCA report from Wiltshire: An opportunity to learn relevant lessons from the above events had therefore been delayed until the inquest; almost a year after events.

Responses

1 respondent

Sussex Partnership NHS Trust NHS Trust

5 Apr 2017 PDF

Action Taken

Sussex Partnership NHS Foundation Trust supplemented Information Governance training for EIP staff with posters on fax receipt. The EIP service developed a transition proforma, a best-practice tool for use by EIP practitioners at the point of transitions into and out of EIP service. The Trust has developed a new Serious Incident Policy. (AI summary)

View full response

Dear Miss Dolan Inquest into the death of Matthew Christopher Roberts Thank you for your report written pursuant to the Coroners & Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and for bringing your concerns to my attention_ Firstly, may offer my sincere condolences to the parents of Mr Roberts and his extended family and friends: am aware that nothing can say will lessen their grief on the tragic loss of their son, however; can make assurances that lessons have been identified and we have agreed some changes to improve our systems and processes These are detailed below; under each of your concerns.
1. That there was no relevant procedure or practice requiring faxes to the Bognor El team be logged and scrutinised so that it might be noted if faxed pages were missing and potentially important information not received. AlI Sussex Partnership NHS Foundation Trust staff must complete Information Governance training annually to ensure that information received and sent is managed safely and effectively. The training includes clear ance on receiving and sending faxes. 88% of staff employed in our Early Intervention in Psychosis Services (EIPS) have completed this training within the last year: Following Mr Roberts' inquest; the Senior EIP Management Team identified the need to supplement this training to ensure the Information Governance Principles were being followed by their staff. Therefore, the team designed and produced posters setting out the guidance around the receipt of faxes. These are displayed above all fax equipment used by EIP staff. Each notice reminds our staff to pass all faxes promptly to the appropriate recipient; to verify all sent pages have been received, and that the sender has confirmed their fax has been received. have also asked the team to ensure compliance reaches 100% with regards to the Information Governance Training: 2 That there was no policy: procedure or practice, requiring a member of the El team to read written information provided by a referrer before the zoning Chair: Caroline Armitage Chief Executive: Samantha Allen Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP WWW sussexpartnership nhs uk teaching trust of Brighton and Sussex Medical School Re: guidz key

meeting and initial risk assessment Additionally it was practice, on occasions, for the information to be left unread until shortly before the first face to face appointment with the patient: Hence the determination of the patient's needs, the current level of risk and the urgency with which the first contact should be made with patient was not informed by all the available information being fully considered The EIP Team Leaders and Senior Clinicians within the EIP service have reflected on this and have developed a clear set of shared standards for accepting referrals. Key elements of the standards are: AII EIP teams to use an updated referral form to gather all relevant information. The EIP Practitioner is to confirm receipt of all referrals received by fax on the day of referral by telephone and to use this telephone call as an opportunity to gather any further relevant information_ The EIP Practitioner will take responsibility for ensuring that all referral information is promptly uploaded or recorded in the patient's electronic health records; our new electronic records systems is called 'Carenotes'_ The EIP Practitioner is to ensure that an up to date risk assessment is received from the referrer whenever the referral is from another mental health team within the Trust or externally, or an initial risk screen is completed in the case of a new patient; previously unknown to mental health services_ The EIP Practitioner is to consider all information provided by the referrer; including information around the presenting risks to help inform them of the clinically indicated response to the referral. The EIP Practitioner is to communicate clearly to the referrer, their provisional plans for making contact with the referred person and the expected timeframes for this The EIP Practitioner is to record the proposed plans for contacting the referred person clearly in the patient's electronic health records on 'Carenotes' . The Daily Zoning meetings will be used to consider all available information on new referrals and decide the clinically indicated responses_ These key elements have been developed by the Service Manager and the Clinical Lead of Sussex EIP into set of guidelines for staff on referrals. These guidelines will be reviewed and signed off by our Sussex Children and Young People's Mental Health Leadership Team by the end of
2017. Following formal sign off;, they will be shared with all EIP teams and practitioners and support will be provided to embed these expected standards 3_ That there was no relevant policy, procedure or practice whereby the Bognor El team would clearly confirm with the referrer the date on which contact with newly referred patient would be made_ EIP staff make robust attempts to engage effectively with their service users. Service users, including those newly referred to the service, are offered choice around 2 May

appointment times and venues for meetings: This helps the service to achieve higher rates of engagement with service users and better outcomes in relation to patient safety and service user recovery. Following a referral to the service, an EIP Practitioner will aim to make telephone contact with the referred client; based on their risk assessment the next working to agree a date and venue for their initial appointment. It is therefore not always possible to clarify at the point of referral, when the service user will be seen: am pleased to say we achieved 95% in February 2017 for the new target for EIP access and waiting times for assessment and treatment to be within 14 days. In cases where significant risks are identified, the EIP service recognises the need to make clear plans around contact and to communicate these clearly and effectively to the referrer and service user in order to reduce the risk; In cases where the service user does not engage with us, the EIP team will follow the Trusts Active Engagement Policy: These elements are also covered in the recently developed set of guidelines for staff on referrals. A transition proforma has been developed by the EIP service following your Regulation 28 report This is a best_practice tool for use by EIP Practitioners at the point of transitions into and out of EIP service. It requires members of the Multi-Disciplinary Team to consider risk issues which may present during the transition and formulate clear plans for responding to these, should occur.
4. That SPFT did not appear to undertaken any formal review of the death of someone known to the organisation and, although SPFT were aware a RCA was being conducted by Avon and Wiltshire NHS Trust; SPFT had not received nor sought that final RCA report from Wiltshire: An opportunity to learn relevant lessons from the above events had therefore been delayed until the inquest; almost a year after events. The Trust has developed new Serious Incident Policy: Justine Rosser, Director of Nursing Standards and Safety is the lead for this new policy which anticipate will be in use Trust wide from next week. This new policy will ensure investigations are carried out to identify learning without delay and follows NHS England guidelines and best practice. In future , when another Trust is leading on a Root Cause Analysis, SPFT will complete local review and feed into the other Trust's investigation to ensure maximum reflection and learning for both organisations is achieved. Thank you once again for raising your concerns with me; Although you confirmed it was not possible to say if the tragic outcome would have been prevented, take each and every death of a service user very seriously: To ensure lessons and improvements to practice are not isolated to one service, the learning from Mr Roberts' death will be shared, anonymously; in the Trust's Quarterly Quality and Safety Report which is circulated Trust wide and is shared externally with our commissioners (CCGs):

Report sections

Investigation and inquest

On April 2016 the Senior Coroner commenced an investigation into the death of Mr Matthew Christopher Roberts. The investigation concluded at the end of the inquest held on 3 February 2017. conclusion of the inquest was that Mr Roberts died on March 2016 from complication of necessary medical treatment; the medical cause of his death (Ia) majot haemorrhage at tracheostomy site (1b) acute arteritis of the innominate artery coma and hypoglycaemia due to mixed and insulin toxicity:

Circumstances of the death

Mr Roberts, who was born on 28 December 1993, was talented music student studying at the University of Chichester: In late 2015 he suffered what appeared to be first of psychosis. This led to him an intentional overdose of insulin in early December 2015 After a brief psychiatric hospital admission under Sussex Partnership NHS Foundation Trust (SPFT) Mr Roberts was discharged to his parents' home in Wiltshire on 24 December 2015. Mr Roberts was supervised and treated, initially, by the Avon and Wiltshire Mental Health Partnership NHS Trust' $ North Wiltshire Intensive Service' team and subsequently by the Wiltshire Early Intervention in psychosis team (the EL team): The transfer the Sussex services to the Wiltshire services over the Christmas period was described as seamless Contact was made with him very shortly after his return and throughout his period in Wiltshire Mr Roberts was seen or spoken to by team members from the Avon and Wiltshire mental health setvices almost daily. It was recognised in Mr Roberts would return to Chichester University in the SPFTs catchment area, and s0 Onl 22 January 2016 the Wiltshire El team made preliminary contact with the relevant Sussex EI team in Bognor who indicted would accept a referral. The being drug episode taking from that; time, they

By 12 Februaty 2016 there had been noticeable improvement in Mr Roberts mental state and in view of the perceived lowered risk of suicide the plan, formed in liaison with the University mental health services was that Mr Roberts would soon return to Chichester and recommence his University studies_ It was recognised that this plan involved some therapeutic risk as his return LO University would, potentially, be a stressful event for Mr Roberts. A risk management plan was therefore devised: It was determined that Mr Robert' s mental state and risk of suicide was such that he would still NHS supervision alongside engagement with the University counselling service on his return to Sussex Indeed the Wiltshire EI team manager described the involvement of the local Bognor EI team as a "crucial' aspect of the risk management plan: Mr Roberts also recognised himself that he needed such support as on 12 February 2016 he asked for the Team which covered the Chichester area to be informed of his impending return and for an appointment to be arranged for the Thursday or Friday of the following week (e. 18/19 February) On Tuesday 16 February 2016 the team manager of the Wiltshire El team made telephone referral to the SPFT Bognor EI team when he spoke to the Bognor team manager_ He informed the Bognor EI team that Mr Roberts was returning to Sussex the following day (although in the event he actually returned on Thursday 18 February). The outcome of that telephone conversation was that the Wiltshire EI team manager understood that Mr Roberts would be offered an appointment with the Bognor El team on Thursday 18 o Friday 19 February 2016. The Bognor El team manger did not; however; share this unders The Bognor team manager told the inquest that when he offered to arrange an appointment for Mr Roberts cthis week he had meant that telephone contact would be made with Mr Roberts within the next days (as was the service standard) and then at that telephone contact future date for a face t0 face appointment would have been arranged with Mr Roberts. Following the telephone conversation between the two EI team managers some supplementary information was faxed by the Wiltshire EI team manager to the Bognor EI team: That was time stamped as arriving at Bognor at around 13.30 hours on Tuesday 16 February 2017. The fax included (amongst other documents): correspondence from a Consultant Psychiatrist to the GP dated 21 January 2016 that set out the psychiatrist's assessment of Mr Roberts' current mental state, progress in treatment and diagnostic formulation; letter the Wiltshire EI team manager to the University counsellor; dated 12 February 2016, out the perceived level of risk and containing the risk management plan; and risk assessment document: The cover page to the fax was clearly marked to show the fax consisted of 22 pages_
10. The following on 17 February 2016 a daily *zoning meeting' was held by the Bognor EI team: At this all new referrals would be allocated to tcamn members and the inquest was informed that there should then have been initial consideration of the patient's clinical needs and the level of risk the patient presented to allow the team t0 formulate plan and determine a response time for taking require standing: fax from setting day, meeting making the first telephone contact with Mr Roberts
11. The evidence of the Bognor EI team manager (confirmed by his immediate line manager) was that there was not always opportunity to read the information sent by referrer before such a meeting, and s0 the practice within the team was tO read the referral information a later time At the latest this would be shortly before the first face to contact with the
12. Mr Roberts' case was allocated to the Bognor EI team manager: However the team manager had not read any of the faxed documents, therefore he relied upon the verbal information provided by the referrer to determine the urgency with which telephone contact should be made: The detailed written information sent by the Wiltshire EI team was not considered by the Bognor EI team to inform the decision-ma regarding the patient s needs and the current level of risk:
13. Indeed, in Mr Roberts' case the Bognor EI team manager had no recollection of ever the faxed material and concluded at the inquest that it was never read by anyone associated with the Bognor team: On considering the fax actually received, which was disclosed part way through the inquest, it was apparent that it was incomplete it was automatically stamped to show it as containing only 17 pages in total (not the 22 noted on the cover sheet) It was immediately obvious on even the most casual review that the Consultant Psychiatrist'$ letter must been missing its opening page Or pages. However neither the Bognor EI team manager nor his immediate line manager were awarc of this before drew it to their attention at the inquest
14. There had been no attempt made by the Bognor EL team t0 contact Mr Roberts when, on 22 February 2016 (the sixth following his referral), Mr Roberts took a overdose of insulin and his prescribed psychotropic medication:
15. Mr Roberts was admitted to ICU at St Richard's Hospital, Chichester in coma suffered significant hypoxic brain damage In the course of his ICU treatment tracheostomy tube was inserted on 2 March 2016. Unfortunately Mr Roberts died some days later on March 2016 when rare but recognised complication of tracheostomy insertion arose. He suffered acute arteritis of the innominate leading to a major haemorrhage at the tracheostomy
16. What precipitated Mr Roberts the overdose Onl 22 February 2016 is unknown and [ concluded that it could not be said that Mr Roberts' overdose would probably have been prevented had there been an earlier appointment with him made by the Bognor EI team; Nevertheless, it is of concern that there was no policy, system_ procedure or practice in place that would have ensured that the Bognor El team promptly considered relevant clinical information sent by a referrer and used that information to inform their determination of the patient's needs and the current level of risk; and hence the urgency with which their first contact should be made:
17. Finally, as was understood that the Avon and Wiltshire Trust would be conducting their own RCA_ there had been no internal review of the events surrounding Mr Robert's care conducted by SPFT: The final RCA report from Avon and Wiltshire Trust; which was completed in June 2016, was not provided to the SPFT and in any event this report focussed on the role of the Wiltshire services zoning face patient: solely aking reading have hearing: day large having artery taking

Hence those shortcomings set out above were not identified until the inquest; an adequate review by SPFT should have revealed matters far sooner:

Action should be taken

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

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During missing zoning meeting patient being patient being duty days setting explain

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Report details

Reference: 2017-0028
Date of report: 9 February 2017
Coroner: Bridget Dolan QC
Coroner area: West Sussex

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: 23 Apr 2017 (estimated).

Sent to

Sussex Partnership NHS Trust

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