Source · Prevention of Future Deaths

Danielle Robinson

Ref: 2016-0205 Date: 31 May 2016 Coroner: John Gittins Area: North Wales (East and Central) Responses identified: 1 / 1 View PDF

Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.

Date 31 May 2016

56-day deadline 27 Jul 2016

Responses identified 1 of 1

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

Coroner's concerns

AI summary

Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.

View full coroner's concerns

That the Therapeutic Engagement and Observation Policy presently adopted by BCUHB is not being rigorously followed by staff with the result that opportunities to escalate the level of observations when required are being missed the

(2) That the current Therapeutic Engagement and Observation Policy there should be reviewed with consideration being given to implementing a system situations where there is a serious event which places a patient at risk of immediate Or imminent harm; that there should be an automatic escalation of observation levels to level 3 or 4 (within eyesight O ar's length respectively) for a designated period and/or one to one engagement with the patient So aS to provide an instant "safety net"

Responses

1 respondent

University Health Board

27 Jul 2016 PDF

Action Taken

The University Health Board has reviewed and updated its Therapeutic Engagement and Observation Policy to include the automatic escalation of observations following a serious attempt of self-harm until a full multi-disciplinary team review can take place; the policy will be formally re-launched at a learning event planned for September 2016. (AI summary)

View full response

Dear Mr Gittins

In response to the Regulation 28, issued on May 28th 2016 as a result of the inquest into the death of Miss Danielle Rhian Robinson. I can confirm that the BCUHB Therapeutic Engagement and Observation Policy has been reviewed and updated to include the automatic escalation of observations following serious attempt of self-harm until a full multi-disciplinary team (MDT) review can take place, a copy is enclosed for your information.

Roles and responsibilities of all staff are clearly detailed within the policy. In relation to the ongoing monitoring of compliance, an audit process is included which will now form part of the divisional audit cycle with outcomes and suggestions for improvements formally reported through our divisional governance structure to QSE.

The division has its first learning event planned for September 2016 and the policy will be formally re-launched at this event.

Report sections

Investigation and inquest

On 20th November 2014 commenced an investigation into the death of Danielle Rhian Robinson aged 21_ The investigation concluded at the end of the Inquest held with a jury on the 25th of May 2016_ The conclusion of the Inquest was that Miss Robinson's death was the result of Misadventure The medical cause of death was I(a) Post Cardiac Arrest Hypoxic Brain Injury with Cerebral Oedema due to 1(b) Ligature Strangulation

Circumstances of the death

Miss Robinson was a 21 year old who was detained under s.3 of Mental Health Act at the Heddfan Unit of Wrexham Maelor Hospital. During the time she was a patient at Heddfan she had repeatedly self harmed, primarily by the placing of ligatures around her neck_ (2) On the 13th of November 2014 she was found unresponsive in her room with a ligature around her neck: At this time, despite earlier episodes of both self harm and absconding from the unit she was on level 1 observations (being every three hours): Despite resuscitation attempts and subsequent treatment she died on the 16th of November 2014_

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:

Similar PFD reports

Shared signals

Report details

Reference: 2016-0205
Date of report: 31 May 2016
Coroner: John Gittins
Coroner area: North Wales (East and Central)

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: 27 Jul 2016.

Sent to

Betsi Cadwaladr University Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.