Source · Prevention of Future Deaths

Mark Daniels

Ref: 2015-0208 Date: 1 Jun 2015 Coroner: ME Hassell Area: London Inner (North) Responses identified: 1 / 1 View PDF

The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.

Date 1 Jun 2015
56-day deadline 27 Jul 2015 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
View full coroner's concerns
You will see from the determination attached, that I found there was a failure by the crisis team:

- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.

I gained the impression of a lack of cohesion and clinical direction.

Responses

1 respondent
Camden and Islington NHS Trust NHS / Health Body
30 Jul 2015 PDF
Action Taken

Camden and Islington NHS Foundation Trust have put in place a comprehensive action plan to address the concerns raised regarding failures by the Crisis team, with measures implemented across all Crisis Teams and Crisis Houses and a plan to monitor their implementation. (AI summary)

View full response
Dear Senior Coroner Hassell Re: Mr Mark Patrick Daniels (deceased) write further to your report on the above dated 1 June 2015 in which you highlighted concerns about the care delivered by the Trust to Mr Daniels_ wish to thank you for bringing your concerns to our attention and am writing to address the issues you have raised and give assurance that we have taken action to prevent future occurrences_ Following the inquest into the death of Mr Daniels you noted the following failures by the Crisis team: a) to visit Mr Daniels twice a despite a plan to do so; b) to record why twice daily visits were not attempted; c) to communicate within the team and with the two Crisis houses; d) to consider hospital admission despite the fact that Mr Daniels was known to have made several suicide attempts; had told he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of a prompt admission to a Crisis house. Associate Divisional Director for the Acute division has considered your concerns and in place a comprehensive action plan to address them the action plan is appended at the end of this letter. As you can see from the action plan updates, several Chair: Leisha Fullick Your partner in Chief Executive: Wendy Wallace care & improvement Camden ISLINGTON C&I Is an NHS Foundatian Trust providing treatment and social care for mental ill-health and substance misuse in adults in partnership with Camden and Islington councils day - staff put

NHS] measures have been put in place across all the Crisis Teams and the Crisis Houses in the Trust to address the concerns you have raised and there is a plan to monitor the implementation of these measures you are satisfied that we have taken action to address the concern which you have very helpfully raised.

Report sections

Investigation and inquest
On 3 December 2014, I commenced an investigation into the death of Mark Daniels, aged 56 years. The investigation concluded at the end of the inquest earlier today. I made a narrative determination, which I attach.
Circumstances of the death
Mr Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. There was an agreement that he be admitted to Rivers Crisis House, but this never took place.
Copies sent to
Care Quality Commission for EnglandProfessor Dame Sally Davies, Chief Medical Officer for England

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2015-0208
Date of report
1 June 2015
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: 27 Jul 2015 (estimated).

Sent to

Camden and Islington NHS Foundation Trust

Source links