Source · Prevention of Future Deaths

Andrew Farrow

Ref: 2015-0147 Date: 20 Apr 2015 Coroner: Peter Hatvany Area: Wiltshire & Swindon 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted that even if the deceased had been assessed as needing admission, no beds would have been available at Green Lane Hospital for his safety.

Date 20 Apr 2015
56-day deadline 15 Jun 2015 stated in the report
Responses identified 1 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The coroner noted that even if the deceased had been assessed as needing admission, no beds would have been available at Green Lane Hospital for his safety.
View full coroner's concerns
The deceased was under the care of the Avon and Wiltshire Mental Health Partnership. The day before his death the deceased made it clear he wished to be admitted to hospital for his own safety_ _ He was known to have suicidal ideation but no actual plan had been formulated. did not find that he ought to have been admitted. My concern however is that had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014 by North Wiltshire Intensive Services_ Wiltshire & Swindon Coroner's Office, 26 Endless Street; Salisbury; Wiltshire, SP1 1DP Tel 01722 438900 Fax 01722 332223

Responses

1 respondent

Avon and Wiltshire NHS Trust

NHS Trust
Letter dated 8 Jul 2015 PDF
AI-classified response stance Noted
AI-generated response summary

• Clinical staff employ various strategies to manage bed pressures, including seeking alternatives to admission, finding beds within the Trust, facilitating discharges, or arranging out-of-area placements. • The Trust makes efforts to repatriate patients sent out of area as soon as possible. • The Trust Board monitors bed pressures and out-of-area placements and collaborates with Commissioners and NHS England to manage the situation.

View full response
Dear Mr Hatvany Thank you for your letter to our Chief Executive regarding Mr Andrew Farrow deceased and the attached Prevention of Future Death (PFD) report: When there is a bed pressure in a locality, clinical staff may take a number of different actions depending upon the requirements of the individual patient. These actions may include seeking alternatives to admission such as intensive home treatment, seeking a bed in another part of the Trust; making a bed available by seeing if there are patients well enough to be discharged, or sending patient out of the Trust's area. The decision is always risk based, and takes account as far as is possible the wishes of the patient and their family: When patient is sent out of area, every effort is made to repatriate them locally as soon as it is possible and in their best interests to do so. The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally_ hope that this information is helpful but please let me know if you require anything further: Whilst writing, would to comment at how surprised was to receive a PFD report for an inquest that we were not a properly interested person in and would like to understand on what basis it was felt necessary to issue a PFD report in this case, given that you found that the patient did not require hospital admission. have recently taken up appointment at Avon and Wiltshire Mental Health Trust and it is important for me to understand how local Coroners work. look forward to hearing from you.

Report sections

Investigation and inquest
On 14 April 2015 concluded an investigation into the death of Andrew Ralph Mitchell Farrow, aged 48 The conclusion of the inquest was Accidental death as a result of acute alcohol and codeine toxicity_
Circumstances of the death
The deceased died as a result of self administered acute codeine and alcohol toxicity at his home on July 2014.
Action should be taken
What action would there have been taken in that eventuality? Would enquiries have been made as to the availability of other beds in other areas such as Callington Road, Bristol?

Similar PFD reports

Shared signals

Report details

Reference
2015-0147
Date of report
20 April 2015
Coroner
Peter Hatvany
Coroner area
Wiltshire & Swindon

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Jun 2015 (stated in the report).

Sent to

Avon and Wiltshire Mental Health Partnership NHS Trust
Department of Health and Social Care

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