Source · Prevention of Future Deaths

Simon Tree

Ref: 2015-0032 Date: 30 Jan 2015 Coroner: Simon Wickens Area: Surrey Responses identified: 1 / 1 View PDF

The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.

Date 30 Jan 2015

56-day deadline 27 Mar 2015 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.

View full coroner's concerns

During the course of the inquest the evidence revealed a matter that gave rise to a concern that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken.

The MATTER OF CONCERN is as follows.  –

During the Course of the Inquest evidence came to light that whilst the door that Simon Tree left the unit from was now secure, there are security issues with the new airlock system.  The Court heard that the onus of releasing people from the unit is placed on ward staff, who operate the airlock system remotely from the ward.  Patients have been able to ‘tailgate’ visitors leaving legitimately and the Court heard 4 people had managed to leave this way in the last 12 months.  On one occasion the camera in the airlock was simply moved to create a blind spot.  A reception area exists beyond the airlock where at times there are staff present with a clear view of who is leaving. These staff appear to plays no roll in monitoring those who are leaving thru the airlock.

Consideration should be taken to address the issue of patients tailgating in the airlock and address the closer monitoring of those leaving the building.

Responses

1 respondent

Surrey Borders Partnership NHS / Health Body

30 Mar 2015 PDF

Action Taken

The Trust has recruited a Security Manager, employs an out-of-hours receptionist, transferred administration support to the wards and improved camera coverage in the airlock. The Trust has also introduced cards outlining duration and conditions of leave and included the concerns raised in their Trust-wide action plan. (AI summary)

View full response

Dear Mr Wickens Inquest into the Death of Mr Simon Tree Regulation 28 Report Action to Prevent Future Deaths Response Further to the conclusion of the inquest into Mr Simon Tree's death on January 2015, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with the Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern: We would firstly, like to take this opportunity to offer our sincere condolences to Mr Tree's family for their loss_ The area of concern you raised that relates to our Trust and our response is detailed below: Consideration should be taken to address the issue of patients tailgating in the airlock and address the closer monitoring of those leaving the building: The risk of absconding is a critical issue in mental health services and we taken number of steps in recent years, such as targeted improvement work on reduction of AWOLS. For example we have introduced cards outlining duration & conditions of leave that people take with them when going on leave. This work is targeted at ensuring that we learn from the events that led to Mr Tree leaving the unit;, and take steps to try and prevent future incidents such as this taking place through effective care planning and risk management processes: For abetter life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD T_0300 55 55 222 F_01372 217111 WWwsabp nhs.uk 23rd have

Since Mr Tree's death, we have recruited a Security Manager who undertakes annual site security audits at all our inpatient sites_ These help us focus our attention on rectifying any weaknesses in our security processes that may enable people to abscond or go AWOL Further to the issues raised about people tailgating through the airlock; we have employed an out of hours receptionist to support the ward staff during visiting hours and have transferred the administration support to each of the' wards between 1Oam and 3pm to focus on the entrance to and exits from the wards: We have also improved the camera coverage within the airlock itself;, so that the whole internal airlock can be viewed through CCTV. We have included the concerns you have raised in our Trust-wide action plan to ensure that there is ongoing leaming from these. We would Iike to offer our sincere condolences again to the Tree family for their loss and hope that the steps we have taken as outlined above assures you and them, that we have learnt and continue to leam from this event Please do not hesitate t0 contact me or Director of Quality and Deputy Chief Executive (DoN), if you require any further iniormaiion.

Report sections

Investigation and inquest

The inquest into Simon Tree’s death was opened on the 21st February 2012 and was resumed on 19th January 2015. It was concluded on 23rd January 2015.

The cause of death found was: 1a – Drowing.

The conclusion was a narrative as follows:

At the time of his death, Simon Tree was a voluntary patient at the Abraham Cowley Unit having originally been sectioned in January 2012 following an attempt at taking his own life. On the 16th February 2012 he was returned to the Unit by Surrey Police having been found by the River Thames in a state of intoxication, expressing a wish to take his own life. As a result he was a known suicide risk and the following morning, 17th February 2012, he was due to be re‐assessed. However, on the RT4496 morning of the 17th February, prior to that re‐assessment a member of staff allowed Simon Tree to leave the ward unsupervised thereby giving him access to an area of the unit where there were known concerns about the security of an exit door. In consequence, Simon Tree managed to leave the unit and was found on the 18th February 2012 in the River Thames at Sunbury Island having drowned. It is unclear how he came to be in the river or what his intention was at the time.

Circumstances of the death

At or about 17.25 hours on the 18th February 2012 Mr Tree was found in the river Thames having drowned. He had left the Abraham Cowley Unit the day before having been given access to an area there were known security concerns

Copies sent to

Simon WickensDATED this 30th day of January 2015

Inquest conclusion

At the time of his death, Simon Tree was a voluntary patient at the Abraham Cowley Unit having originally been sectioned in January 2012 following an attempt at taking his own life. On the 16th February 2012 he was returned to the Unit by Surrey Police having been found by the River Thames in a state of intoxication, expressing a wish to take his own life. As a result he was a known suicide risk and the following morning, 17th February 2012, he was due to be re‐assessed. However, on the RT4496 morning of the 17th February, prior to that re‐assessment a member of staff allowed Simon Tree to leave the ward unsupervised thereby giving him access to an area of the unit where there were known concerns about the security of an exit door. In consequence, Simon Tree managed to leave the unit and was found on the 18th February 2012 in the River Thames at Sunbury Island having drowned. It is unclear how he came to be in the river or what his intention was at the time.

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Report details

Reference: 2015-0032
Date of report: 30 January 2015
Coroner: Simon Wickens
Coroner area: Surrey

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 Mar 2015 (estimated).

Sent to

Surrey and Borders Partnership NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.