Source · Prevention of Future Deaths

Colin Tyson

Ref: 2015-0080 Date: 4 Mar 2015 Coroner: Nicola Mundy Area: South Yorkshire (East) Responses identified: 1 / 1 View PDF

Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.

Date 4 Mar 2015

56-day deadline 7 Apr 2015

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.

View full coroner's concerns

In the circumstances it is my statutory to report to you: (1) Concern regarding GPs interpretation of patient confidentiality preventing concerned family members passing pertinent information regarding vulnerable persons who are potentially at risk of suicide_

Responses

1 respondent

NHS England NHS / Health Body

24 Sep 2015 PDF

Action Planned

NHS England, working with NHS Wakefield CCG, has developed an advice sheet for GP practices on responding to third-party concerns about patients, which will be shared across Wakefield and Yorkshire and the Humber. This information will also form part of safeguarding training for practices. (AI summary)

View full response

Dear Ms. Mundy Re: Colin Tyson (deceased) your ref NJMphltji/46194-23014 am writing to you following your letter on March 2015 requesting details of action taken following Colin's death: have been in contact with NHS Wakefield Clinical Commissioning Group as | outlined in letter to you of 18th
2015. have also had the opportunity to meed withsthetamiey Of Mry Tyson to discuss the actions we have planned to undertake. will be to Mr. Tysons family separately to advise them of the actions we have taken: the clinical advisor to NHS Wakefield CCG, has visited the practice concerned and spoken with the GP who assessed and treated Colin who was pleased to have opportunity to contribute to the joint NHS England and Wakefield CCG response We have worked together to develop an advice sheet for GP practices on the appropriate response when third parties raise concerns or request sharing of information about a patient registered at the practice. As you rightly noted this is an area which many practices do not feel confident about and hence there is a risk that relevant and important information does not reach the patient's GP attach a copy of this advice sheet for your information. It will be shared with all GP practices in Wakefield by the CCG and across Yorkshire and the Humber by the safeguarding networks In addition we will disseminate this information to all GPs in conjunction with the Local Medical Committees in every district. The advice contained within the advice sheet will also form part of the training that is offered to practices in relation to the safeguarding ocadultsand childrear South West Yorkshire Partnership Foundation Trust who provided the hospital and mental health services in this case are implementing the actions to community assessment, communication and follow-up which the review of Colin s death raised The Head of Quality High quality care for all, now and for future generations City ~ECEIVEL 236 2 . YCY College the May writing the relating

and Engagement at Wakefield CCG is monitoring the implementation of these actions to improve care for future patients have advised Mr: Tyson's family that would be happy to support any work undertake to raise awareness of mental health issues with the MIND charity. am grateful to you for raising these matters with the NHS, think that the actions taken result of_your intervention will improve the safety and quality of services for as a future_ Please let me know if you require any further information. patients in the

Report sections

Investigation and inquest

On 13/08/2014 commenced an investigation into the death of Colin Tyson, 51 The investigation concluded at the end of the inquest on 10 February 2015. The conclusion of the inquest was Suicide. The cause of death was: Ia. Severe, extensive external and internal injuries and fractures 1b. Railway collision

Circumstances of the death

Mr Tyson was a private man who had being significantly affected by a physical injury that had limited both his to his sports, for which he had a real passion, and had also led to him off work for quite some time which was significant for a man who had such a strong work ethic It was clear that he was struggling to deal with these issues and perception as to how others might now be viewing him . He attempted to end his life on the 6th August 2014 by way of carbon monoxide poisoning from his car but was taken to hospital and resuscitated. mental health assessment took place in hospital where he denied further suicidal ideation. An assessment by the general practitioner of the 7th August led to him again assessed as not requiring any acute psychiatric input. Accordingly no referral was made to the psychiatric services at this time. It became clear during the course of the evidence from family members that Mr Tyson continued to harbour thoughts of suicide and had even been planning how he might do this. On the 11th August 2014 Mr Tyson stepped in front of a high speed train, dying instantly as a result of the impact family expressed grave concerns regarding their efforts to pass on information to the GP in the community when tried to express concerns to the GP. The concern from the GP practice related to patient confidentiality issues am quite satisfied that the family members did have pertinent information which would have benefitted the GP in his assessments_ There is a need for there to be a way in which concerned family members of vulnerable persons (even if not under the usual category of a child or an elderly patientlperson) should be able to pass on relevant information to the general practitioner. Whilst am not convinced this would have altered the outcome in Mr Tyson's case it may well make all the difference in some cases where persons arein a particularly vulnerable state to life events at that time. The general practitioner (shared those concerns and was taking matters back to his private practice but as | felt this raised wider issues for many GP practices ie where GPs might interpret patient confidentiality to extend to not being able to receive critical information. wish to draw these matters to your attention: Coroner'$ Court and Office; Doncaster Crown Court, College Road, Doncaster, DNI 3HS Tel 01302 320844 Fax 01302 364833 ability enjoy being his being The they their falling due

Action should be taken

Inmy opinion action should be taken to prevent future deaths and believe you Director Of Quality and Nursing have the power to take such action:.

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Shared signals

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Report details

Reference: 2015-0080
Date of report: 4 March 2015
Coroner: Nicola Mundy
Coroner area: South Yorkshire (East)

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: 7 Apr 2015.

Sent to

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.