Source · Prevention of Future Deaths

Benjamin Orrill

Ref: 2016-0367 Date: 19 Oct 2016 Coroner: Christina Swann Area: Leicester City and Leicestershire South 2 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner identified that there is no regulatory body for advanced nurse practitioners, meaning they are not subject to the same stringent appraisal and revalidation processes as GPs and some may operate without supervision. This lack of regulation could impact patient safety.

Date 19 Oct 2016
56-day deadline 14 Dec 2016 stated in the report
Responses identified 2 of 2
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)

Coroner's concerns

AI summary
The coroner identified that there is no regulatory body for advanced nurse practitioners, meaning they are not subject to the same stringent appraisal and revalidation processes as GPs and some may operate without supervision. This lack of regulation could impact patient safety.
View full coroner's concerns
During the course of the Inquest it came to my attention that there is no regulatory body for advanced nurse practitioners. It would appear they are not subject to the same stringent appraisal and revalidation processes such that GPs currently are, despite the fact that they may perform similar duties and can have parallel roles. also became aware that some advance nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal. Therefore some may potentially be operating as independent practitioners without any supervision or regulation. I am concerned that this may have a significant impact on patient safet . I. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

Responses

2 respondents

NHS England

NHS / Health Body
Letter dated 29 Nov 2016 PDF
AI-classified response stance Noted
AI-generated response summary

• NHS England stated that it expects general practices to complete an annual electronic general practice self-declaration (eDEC) to confirm that staff possess the necessary knowledge, experience, qualifications, and skills. • The eDEC also requires practices to confirm that all employed healthcare professionals undergo annual appraisals and have personal development plans, aligned with revalidation requirements.

View full response
Dear Dr Swann Re: Regulation 28 reportto preventfuture deaths: Benjamin Orrill note receipt of the above report of the 19th October made under paragraph 7, Schedule 5 ofthe Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners(Investigations) Regulations 2013. also note that this report has been sent to as Chief Executive of the Nursing and Midwifery Council(NMC). My sympathies go to the family of Mr Orrill and thank you for drawing my attention to the concerns as outlined. within your report. I would like to address them individually as set out below:
1.0 There is no regulatory body for advanced nurse practitioners: NHS England has nc~ jurisdiction over the regulation of nurses. The NMC is the body which sets standards of education,training, conduct and performance and ensures that nurses and midwives keep their skills and knowledge up to date and uphold professional standards. They have processes to investigate nurses and midwives who do not meet those requisite standards and maintain a register of nurses and midwives allowed to practice in the UK.
2.0 Advanced nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal;and therefore may be operating as independent practitioners without any supervision or regulation: Again NHS England has no mandate in relation to registered nurses who have chosen to practise independently. Those registrants remain accountable to the NMC as their regulatory body and through a process of professional revalidation are expected to maintain their registration.

However, NHS England as the commissioner expects general practices to complete within the annual electronic general practice self-declaration(eDEC)that they recognise the need to have the right knowledge,experience, qualifications and skills for the purpose of providing services in the practice and demonstrating capacity to respond to unexpected service changes.. The eDEC also states that all health care professionals employed in the practice have annual appraisals and where applicable personal development plans and that this is aligned to revalidation for doctors and also for registered nurses and midwives(according to requirements issued by the Nursing and Midwifery Council). As previously mentioned I note that as Chief Executive ofthe NMC has also been sent this report and she will be able to provide more detail on the regulatory aspects signposted above.

NMC

Regulator / Inspectorate
Letter dated 20 Jan 2017 PDF
AI-classified response stance Noted
AI-generated response summary

• The NMC provided a document summarising its statutory framework and information on advanced practice. • The NMC stated it would not be taking further action in response to the concerns raised. • The NMC indicated its belief that its existing statutory framework and revalidation process are sufficient to protect the public.

View full response
Dear Madam Benjamin Orrill Further to your Report to Prevent Future Deaths made under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners (Investigations) Regulations 2013, I am writing to provide you with our response. We note the concerns you have raised relating to the regulation of advanced nursing practice. To help explain how we fulfil our statutory objective to protect the public, we have enclosed with this letter a document that summarises our statutory framework and provides background information about advanced practice. We are aware of the particular concern raised about the registered nurse who reviewed Mr Orrill in the weeks leading up to his death. We are working closely with you in relation to this and are considering the concerns in accordance with our statutory functions. We will not be taking any further action in relation to the concerns you have raised because, for the reasons we summarise in the enclosed document, we believe that our statutory framework and the process of revalidation are sufficient to protect the public in respect of advanced practice. hope that the attached information is helpful, If we can provide any further input on this matter, please do not hesitate to contact me again.

Report sections

Investigation and inquest
On 13th June 2016 I commenced an investigation into the death of Benjamin Orrill. The Inquest concluded on 19th September 2016 Cause of death: 1a Multiple injuries Conclusion: Suicide
Circumstances of the death
Mr. Orrill died on 12th June 2016 following a fall from Lee Circle NCP car park, Leicester. He had been reviewed by an advanced nurse practitioner in the weeks leading up to his death due to feeling suicidal. There was a missed opportunity to appropriately assess the severity of Mr. Orrill's low mood, however there was no evidence heard to suggest that this would have prevented the outcome. Police investigation concluded that there were no suspicious circumstances, that these were Mr. Orrill's own actions and that he did intend the outcome.

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Report details

Reference
2016-0367
Date of report
19 October 2016
Coroner
Christina Swann
Coroner area
Leicester City and Leicestershire South

Responses identified

Responses identified 2 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 Dec 2016 (stated in the report).

Sent to

NHS England
Nursing and Midwifery Council

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