Source · Prevention of Future Deaths

Leah Levine

Ref: 2015-0093 Date: 11 Mar 2015 Coroner: John Pollard Area: Manchester (South) Responses identified: 1 / 1 View PDF

Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting staff understanding and poor communication with caregivers.

Date 11 Mar 2015
56-day deadline 6 May 2015
Responses identified 1 of 1
Mental Health related deaths

Coroner's concerns

AI summary
Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting staff understanding and poor communication with caregivers.
View full coroner's concerns
The MATTER OF CONCERN is as follows. When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital; it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What the level and frequency of such supervision should be: what; if any, observation regime should be put in place: and nothing was reduced to writing and given to those taking her from the hospital: Consequent on the above, there was conflicting evidence from different members of the medical and nursing staff as to what exactly was expected and put forward as required: ActION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: Urgent consideration should be_given to putting in_place a requirement for such The got -

home leave requirements always to be set out in writing and a copy be given at the time to the person having care of the patient whilst on leave.

Responses

1 respondent
Greater Manchester West NHS NHS / Health Body
30 Apr 2015 PDF
Action Taken

The Salford Directorate developed a procedure for granting leave to informal patients with family and friends, outlining considerations for the multidisciplinary team. This procedure will be implemented by May 31st, 2015. (AI summary)

View full response
Dear Mr Pollard 86 /2675 Re: Ms Leah Levine DOB 18/02/65 (Deceased) 05/10/14 Further to your letter dated 11th March 2015 regarding the Regulation 28: Report to Prevent Future Deaths of the Coroners Rules 2013 in Which you raised the following concern: When it wasenegotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What level and frequency of such supervision should be: what; if any, observation regime should be put in place: and nothing was reduced to writing and given to those taking her from hospital: will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken Whilst granting leave for a service user in ouracares These include medication management, supervision, crisis plan, home based treatment support if applicable enclose a copy of the procedure for your information_ In order to share the learning from Ms Levine's death and following the concerns raised during your inquest; the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 310r
2015. that this response provides assurance to Ms Levine's family and yourself and that demonstrates how GMW has measures in place to ensure that the of our services users is fundamental to the care we deliver.

Report sections

Investigation and inquest
On 8th October 2014 commenced an investigation into the death of LEAH LEVINE dob 18th February 1965_ investigation concluded on the 27th February 2015 and an Open Conclusion was recorded: The medical cause of death was 1a Multiple Injuries. CIRCUMSTANCES OF THE DEATH On the 5t October 2014 She was staying with a Rabbi friend when she through a window on to the roof of the house and then either jumped or fell to her death:

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Report details

Reference
2015-0093
Date of report
11 March 2015
Coroner
John Pollard
Coroner area
Manchester (South)

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: 6 May 2015.

Sent to

Greater Manchester West Mental Health NHS Foundation Trust

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