Source · Prevention of Future Deaths

Jonathan Lander

Ref: 2016-0114 Date: 18 Mar 2016 Coroner: Geraint Williams Area: Worcestershire 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted the absence of a policy or procedure for following up individuals discharged from one service to another, observing that a previously agreed action plan for this had not been implemented since 2015.

Date 18 Mar 2016

56-day deadline 13 May 2016 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted the absence of a policy or procedure for following up individuals discharged from one service to another, observing that a previously agreed action plan for this had not been implemented since 2015.

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During (he coursa Df the Inquest the ew dence revealed matters giving risa t0 concern In my opirion there is a risk that future Ceaths will occur unless action is taken; In the circumstarzes it i5 MY statutary duty t reportto You Tha MATTERS QF CONCERN are 38 follows {1} That there Is not In Flace any polcy Or procedure tor [ha tolawing up Qf Individuals wha are #2en Dy One GETYice and [herealler d %charged to anather service In the coursa of Ine inguest was Frovided wth a Root Cause Analysis which identifed the merticned above and which containad an actipn plan indicating that such & policy proredure was to bP implemented by September 2015 was told in the coumse of the inquest thatthat policy procedure has not baen implemented, was laf with tne serse thatthis ia still io ba czns Jered but there Appears to be no wense of urgerty was furtner tcld tnat tha Tnusi has a governance prccedure t0 ersure thai acticn plans are "fcllowed through" put it weems tc pe clearly the case that this nas not worked either tne the being falling respectfully sugge8t that you consider Urgenlly Ihe necessity for a such J procedure / policy and t0 Implemgnt Il 2p {31 ACTION shouLD BE TAKEN In my opiion aclion shoud ne taken t2 prevant future deaths ad believe You have Ihe powe: lo lake such action;

Responses

1 respondent

J Lander

Indexed date: 12 May 2016 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Trust has implemented an agreed Substance Misuse Information Sharing Protocol with Swanswell Worcestershire Recovery Partnership. • The Trust has established an Embedded Lessons Database. • Action plans from individual Root Cause Analyses are now uploaded to this database with evidence of completed actions.

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Dear Mr Wlliam; Johnathan James Lander (Doceased) Thank you (or your letter dated 22 March 2016 issued pursuant to Regulatian 28 cf the Coroner: Regulations Fallowing the inquest the Trust now has in place an agreed Substance Misuse Inforratrion Sharing Protocol between itself and Swanswell Worcestershire Recovery Partnership encloze & copy for your Ba8e Df reterence The puipose of ihe protocol is Io erisure relevant clinical and otrer material information Is shared where there are concerns regarding patieni $ menlal health ad subatance misuse Ip ensure that services have UP Io date informaticn and Ihal patierts will receive the appropriate treatmert bath agencies_ can advise In relaticn [o & govemance procedure to implement the Action Plans set out in individual Root Cause Analyses thaf the Trust ncw' has an Emherded Lessons Database AIl the Action Plans sot out in Individual Root Cause Analyses aTa now uploaded t0 that database together wilh evidence of completed actions, This database is mcnitored by Ine Coverance Team based in the Ajult Mental Health and Leamning Disability Service Delivery Unit note that the issues ralsed In thiz cage may be l relevance to thcse Froviding healncare services in alher Trusts nationally an can see that tnere may b2 merit in the Chief Coroner publishing either 3 :ummary ar redacted form of cur correspondence shall be graleful If you cculd kindly sond a copy of my letter tol hope the above addresses Your concerns however_ if You have any quenes do not hesitale to ccntact me.

Report sections

Circumstances of the death

On 28" Aprl 2015 Mr Lander %as killed when he was struck by a brain on Ihe bracks near to Black Bndge, Woicester Rcad Hartlebury.

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Shared signals

Report details

Reference: 2016-0114
Date of report: 18 March 2016
Coroner: Geraint Williams
Coroner area: Worcestershire

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: 13 May 2016 (estimated from the report date).

Sent to

Worcestershire Health and Care NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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