Source · Prevention of Future Deaths

Daniel Williams

Ref: 2014-0009 Date: 6 Jan 2014 Coroner: Nicola Mundy Area: South Yorkshire (East) Responses identified: 1 / 1 View PDF

Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.

Date 6 Jan 2014

56-day deadline 3 Mar 2014 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

(1) Quality of staff training, particularly with regard to record keeping and communication.

(2) The emphasis on taking a holistic approach to care and whether there is an imbalance between adopting such an approach and patient safety.

(3) The absence of clear guidance for checking patients and their rooms for potential self harm items both in the rooms themselves and for items brought into the hospital.

(4) The absence of a single reference sheet in the notes summarising key issues, risk factors, significant incidents and concerns readily accessible to all involved in patient care.

Responses

1 respondent

Response

PDF

Action Taken

The Trust has implemented a patient record development programme which provides alerts to staff, states a patient centred approach, and has rolled out training for staff and improved patient handovers. They also state to have developed guidance for staff and patients to provide detailed information. (AI summary)

View full response

aje? Juaijed Ui paNOAUI Ile 01 aiqissap3e uopaiduop? Kipeaj sujajuo? JO} aieos awi} sujajuo? Jayio Kue pue 'sluapi?ul Jueoyiubis 01 se JapiAOJd a?iNas pue sjuapijui Jueniiubis 'ueid Juauabeueu 'sjop?E} XSU 'sanssi SpJODa %iuoJjaIa pue XSu JuaJJn? 6ulullino a6ed JuOJ e apnppul buisueuuns sa1ou Juajn? a4} WOJy 0} auluejboud juaudojanap pJODaJ Juaned a4} UI JaayS 3juajajaj uoieziiou 6unemV piu0J12ala 4} Olul Jlinq uaaq sey anssi SlyL 2buis eJO apuasqe Slaleai uOHelJogui uoissiupe Juaned 24} Ul papnpul uaaq a^eY uoissiupe uO saypjeas sayjjeas WOOJ bulpjebaJ sluauaieis "YpJeas e yons J0 buipojaJ 341 pue pajonpuo? aq 01 YjJBOS @ JO} paau 94} 0} U3n6 aq pinoys 'Ieldsoy a4} OJU! 1ybnojq uonejapisuo? Uaym auepinb Ilelap @JOU Y1IM SLu?II JO} pue saNasWa4} HeIs pJBM apIAOJd 0} Sl anpajold bullejado SuooJ a41 UI Yloq Suual pJepueis a41 JO ue &41 :Kuadoud Jay} wjey-Jlas Ielluaiod JOJ #loz Kuenjqay pua JO uoSJad e J0 bulypjeas a41 Jo Kolod JsnuL SWOOJ Jiay} pue squaned palllej pue Juaulo? a4} Mojaq IIS 0} padojanap uaaq sey saypjeas bulxpay? JO} apuepinb JOJ painquISip &q 0L WOoJ JO} ainpapold bullejadQ pJepueis Jeap? J0 ajuasqe a41 (dioh) diysjaujed JuauaAoudui Kvlleno ajeoulleaH J41 Kq pauoissiwuo? pue (HSION) ssauill IejuaW 41IM aidoad Kq appiuoH pue apppins ojul Muinbul Ieqluapiuo? IeUOIEN 94} Kq pai SEM SI41 ELoz &unc 'Kpnis jolld V : apijiuoh pue apppins 01 JOUd JuaussassV XSIY J0 Kileno, WOJY suollepuauwojau pue sbuipuy Najes "pajaiduuo? a4} sapnpu} osie bujujeJ} &41 auuejbojd ay} Jualed pue ypeojdde ue a^eY Heis Ile Ivun bulpuaue Ile aJe HeIS Juailedul pue squauwo? ypns uaamaq ajueiequi bujuunu awwejbojd S,auojoj a41 pue }uapi?ui WoJy bujujeai ue Sl ajay} Jayiaym pue KixaaM #loz Nuenuer 341 sajejodJoDul 1eY} Bujuleu} Juauabeueu aje? 01 ypeojdde DI1SIIOY 01 pajuawloj XSIJ axodsaq auos paubisap sey IsnuL 94L buxe} uo siseydua a41 'HeIs Ile 01 paieoiunuwos aq ue? uoilejuasajd pue ssajbojd 'XSU J0 Eloz spjojaJ pue JaiopueY OJUI uaxe} aje sueid ajej Jaquapad] pajuawwoj sjuanjed JeY} OS pajaile sey apipe1d Ja^opueH buidaax suoJieU ujapou pJojaJ JO} spjepueis YIIM aoueiiduo? JOlluOu Kq buuouou Kxeam O} apeid Ul aje slpne ueid aje? J0 a1OqE aouapia 0} aiqeileae Spjojaj bujuesL 'uolleoiunuuo? pue buldaax pJojaJ Eloz bujuuejd auJe? pasieuosjad, paueu bulujeal-a 0} puebaJ U! Kpueinowuued JaquaAON pajaiduo) pue sxoed bujulej} YIIM panssi HEIS Juailedul IIV 'bujuieJ} JeIs jo Kvileno S37V3S3WIL NaXVL SNOIJOV NJBONO? Kax 341 pue S4} waisks

Report sections

Investigation and inquest

On 21st June 2013 I commenced an investigation into the death of DANIEL WILLIAMS, AGE 24. The investigation concluded at the end of the inquest on 2ND JANUARY 2014. I concluded that the cause of death was 1a HANGING and returned a NARRATIVE CONCLUSION as follows:

In May 2013 Daniel Williams was admitted to St Catherine’s Hospital following an episode of deliberate self harm by way of insulin overdose. This was on a background of psychiatric problems which developed following a diagnosis of diabetes which had profoundly effected him.

During the course of his admission superficial enquiries by staff and unreliable record keeping compromised the quality and completeness of the clinical information which in turn compromised the effectiveness of the risk assessments. Poor communication exacerbated matters. All these factors served to further increase Mr Williams’ significant risk of self harm.

On 15 June 2013 Daniel Williams died from hanging following self application of a ligature in his room at St Catherine’s Hospital.

Circumstances of the death

Daniel Williams had been diagnosed as suffering from Diabetes as the age of 19. This profoundly affected his mental wellbeing and also had physical implications too. As a consequence he engaged with the psychiatric services and his final admission to hospital was on the 23rd May 2013 following an overdose of insulin. Mr Williams suffered from suicidal thoughts for much of that admission and appeared to be considering alternative methods for ending his life. There were a number of risk assessments and one to one meetings, many of which appeared not to explore in any depth his suicidal thoughts and intent. On the 15th June 2013 Mr Williams hanged himself with a bedsheet by knotting one end and securing it in the door jamb to the en suite bathroom and tying the other end tightly around his neck.

Inquest conclusion

In May 2013 Daniel Williams was admitted to St Catherine’s Hospital following an episode of deliberate self harm by way of insulin overdose. This was on a background of psychiatric problems which developed following a diagnosis of diabetes which had profoundly effected him.

During the course of his admission superficial enquiries by staff and unreliable record keeping compromised the quality and completeness of the clinical information which in turn compromised the effectiveness of the risk assessments. Poor communication exacerbated matters. All these factors served to further increase Mr Williams’ significant risk of self harm.

On 15 June 2013 Daniel Williams died from hanging following self application of a ligature in his room at St Catherine’s Hospital.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2014-0009
Date of report: 6 January 2014
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: 3 Mar 2014 (estimated).

Sent to

Rotherham, Doncaster and South Humberside NHS Foundation Trust

Part of a series

2 reports

2019-0309 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.