Dale Proverbs
PFD Report
All Responded
Ref: 2015-0010
All 1 response received
· Deadline: 3 Mar 2015
Response Status
Responses
1 of 1
56-Day Deadline
3 Mar 2015
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
That there were, at the time of Mr Proverbs death; Partnership In Care Policies in place that created a higher standard of observation required for patients on seclusion than the Code of
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) Practice for The Mental Heath Act 1983 prescribed. The Partnerships In Care Policies in place at the time of Mr Proverb' s death if followed, are likely to have prevented his death: If the Code of Practice for the Mental Heath Act 1983 were to be followed by Partnerships In Care, which is now their policy, then the Jevel of observation for patients in seclusion would not be enough to prevent another fatality were the circumstances to be the same as those surrounding Mr Proverbs death:
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) Practice for The Mental Heath Act 1983 prescribed. The Partnerships In Care Policies in place at the time of Mr Proverb' s death if followed, are likely to have prevented his death: If the Code of Practice for the Mental Heath Act 1983 were to be followed by Partnerships In Care, which is now their policy, then the Jevel of observation for patients in seclusion would not be enough to prevent another fatality were the circumstances to be the same as those surrounding Mr Proverbs death:
Responses
Response received
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From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Department Richmond House of Health 79 Whitehall London POCS 913654 SWIA 2NS Tel: 020 7210 4850 Mr A Walker Senior Coroner HM Coroner' s Court 17 MAR 2015 29 Wood Street High Barnet ENS 4BE Qea_ NV WaMko Thank you for your letter following the inquest into the death of Dale Proverbs_ Iwas very sorry to hear of Mr Proverbs' death and wish to extend my sincere condolences to his family. Mr Proverbs had been detained under the Mental Health Act 1983 and placed in seclusion at a north London clinic, run by Partnerships in Care (PIC) While at the clinic, Mr Proverbs was intended to be under continuous observation, as stipulated in PIC policy. A nurse was assigned to observe Mr Proverbs However when Mr Proverbs collapsed in his room it was not noticed until 15 _ 20 minutes after the nurse's last direct observation and communication An ambulance was called, but Mr Proverbs suffered a ventricular fibrillation which led to his death_ You state that the use of Clopixol is the most likely of a number of possible causes of the ventricular fibrillation that led to Mr Proverbs' death: You also say that neglect shown in the lack of implementation of PIC policy on continuous observation of a patient in seclusion contributed to Mr Proverbs' death: I understand that in response to the issues raised at the inquest, PIC redrafted their policies to conform exactly to the 2008 Mental Health Act 1983 Code of Practice. appreciate that you consider that the PIC policies in place at the time of the death demanded a higher standard of observation for secluded patients than is detailed in the Code of Practice. However; the Code of Practice reflects the government's commitment to improving mental health services, and to protecting the most vulnerable in society and has recently been revised to reflect substantial changes and updates in legislation, policy, case law, and professional practice.
Staff failure in this case to adhere to the standards of observation set out either in PIC $ own policy or in the Code of Practice are matters for PIC management: I note that you have sent a copy of your Regulation 28 letter to PIC and I would expect them to address any such outstanding issues Your main concern is however that the levels of observation recommended in the MHA Code of Practice for patients in seclusion are not sufficient enough to prevent a death from occurring in similar circumstances_ The Mental Health Act 1983 Code of Practice states that a suitably skilled professional should be readily available within sight and sound of the seclusion room at all times throughout the period of the patient'$ seclusion. The Department of Health has recently completed a thorough review of the Mental Health Act 1983 Code of Practice which, subject to parliamentary approval, will come into effect on 1 April 2015. As part of this procedure the requirements for reviewing seclusion have been strengthened with changes to the and frequency of formal reviews of the ongoing need for seclusion: The draft considered by parliament requires that seclusion should be 'applied flexibly and in the least restrictive manner possible, considering the patient'$ circumstances The overall requirement for observation quoted above has not been changed, However; for patients who have received sedation there is a requirement that a skilled professional is outside the door at all times. The Code goes on to explain that 'the aim of the observation is to safeguard the patient, monitor their condition and behaviour and to identify the earliest time at which seclusion can end '. This acknowledges the importance of proper observation but also takes account that constant observation is not always appropriate and could in some circumstances be more restrictive than is necessary The National Institute for Health and Care Excellence (NICE) is currently developing guidelines for the management of violence and aggression: Their consultation draft takes similar approach to the Code, with a higher level of observation required where patients have been sedated, In addition, the National Confidential Inquiry into Suicide and Homicide (NCISH) is currently undertaking review of constant and intermittent observation on mental health units entitled, 'In-patient suicide under non-routine observation and will publish results in March 2015. Following this, NHS England is planning work with other organisations to ensure that findings of the NCISH report; including those which relate to improving the reliable delivery of effective observation, are considered and implemented. timing being
Ihope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Proverbs' death to my attention. {48 Ixy , DR DAN POULTER
Staff failure in this case to adhere to the standards of observation set out either in PIC $ own policy or in the Code of Practice are matters for PIC management: I note that you have sent a copy of your Regulation 28 letter to PIC and I would expect them to address any such outstanding issues Your main concern is however that the levels of observation recommended in the MHA Code of Practice for patients in seclusion are not sufficient enough to prevent a death from occurring in similar circumstances_ The Mental Health Act 1983 Code of Practice states that a suitably skilled professional should be readily available within sight and sound of the seclusion room at all times throughout the period of the patient'$ seclusion. The Department of Health has recently completed a thorough review of the Mental Health Act 1983 Code of Practice which, subject to parliamentary approval, will come into effect on 1 April 2015. As part of this procedure the requirements for reviewing seclusion have been strengthened with changes to the and frequency of formal reviews of the ongoing need for seclusion: The draft considered by parliament requires that seclusion should be 'applied flexibly and in the least restrictive manner possible, considering the patient'$ circumstances The overall requirement for observation quoted above has not been changed, However; for patients who have received sedation there is a requirement that a skilled professional is outside the door at all times. The Code goes on to explain that 'the aim of the observation is to safeguard the patient, monitor their condition and behaviour and to identify the earliest time at which seclusion can end '. This acknowledges the importance of proper observation but also takes account that constant observation is not always appropriate and could in some circumstances be more restrictive than is necessary The National Institute for Health and Care Excellence (NICE) is currently developing guidelines for the management of violence and aggression: Their consultation draft takes similar approach to the Code, with a higher level of observation required where patients have been sedated, In addition, the National Confidential Inquiry into Suicide and Homicide (NCISH) is currently undertaking review of constant and intermittent observation on mental health units entitled, 'In-patient suicide under non-routine observation and will publish results in March 2015. Following this, NHS England is planning work with other organisations to ensure that findings of the NCISH report; including those which relate to improving the reliable delivery of effective observation, are considered and implemented. timing being
Ihope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Proverbs' death to my attention. {48 Ixy , DR DAN POULTER
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action:
Report Sections
Investigation and Inquest
On the gth February 2012 opened an inquest touching the death of Dale Owen Ricardo Scott Proverbs 21 years old: The inquest concluded on the 8' December 2014. The conclusion of the inquest was Narrative" , the medical case of death was Ia Sudden adult death in a person with Schizophrenia_
Circumstances of the Death
The narrative conclusion sets out the facts_ On the 22"d January 13.30 Mr Proverbs was placed in seclusion at the North London Clinic where he was a patient detained under the Mental Health Act 1983. Mr Proverbs was, whilst in seclusion to be placed under continuous observation. Mr Proverbs was last observed at around 19.00 hrs when he spoke to a member of staff who was observing him through the seclusion room window. Mr Proverbs asked to speak to the nurse who was carrying out the period of observation and that interaction was the time that Mr Proverbs was seen last -
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) alive. Between 15 to 20 minutes later a member of staff looking through the seclusion window noticed that Mr Proverbs was unwell and the alarm was raised The nurse who was responsible for carrying out continuous observations was sitting On a sofa and did not have Mr Proverbs in his sight at the time that he collapsed. An ambulance was called at 19.22 and arrived at the hospital at 19.29 and the ambulance staff reached Mr proverbs at 19.32 Hrs. The Hospital policies in place at that time required continuous observation of a patient in seclusion and this did not happen resulting in Mr Proverbs collapse not being witnessed and as a consequence Mr Proverbs death was contributed to by neglect The use of Clopixol played a more than minimal or trivial contribution to Mr Proverbs death in that it is the most likely of a number of possible causes of the ventricular fibrillation: (End of narrative conclusion) Care at the North London Clinic was provided by Partnerships In Care. There are 3 documents that deal with the question of observation in seclusion and these are firstly the Code of Practice Mental Health Act 1983 Clinical Practice Guidelines Violence The short-term management of disturbed /violent behaviour in in-patient
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) psychiatric settings and emergency departments. 2005/2006 North London Clinic Hospital Policies. It seems to me that the purpose of these policies is to ensure that seclusion is properly used and managed safely. Mr Proverbs was transferred to the North London Clinic on 21st October under Section 48. The use of seclusion was determined using Policy 94 together with other relevant policies and the code of Practice for the Mental Heath Act. Policy 94 which is titled NURSING PATIENTS IN SECLUSION AND LONGER TERM SEGREGATION. The introduction sets out that Nursing patients in seclusion Or in longer term segregation can be complex and require clear guidance to promote good practice within the Partnerships In Care. The policy sets out the context and framework within which Partnerships In Care staff will practice. The policy is to be read in conjunction with Mental Heath Code of Practice England and Wales
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) Partnerships In Care operational policies Safe and Supportive Observations Reviewing of incidents and untoward occurrences Guidelines for the use of rapid tranquilization Health Record and Management Partnerships In Care Operational Policy. The Partnerships In Care policy where under the heading observation the following sets out:- The aim of the observation is to monitor the condition and behaviour of the patient, specifically in relation to the reason for the seclusion and to encourage de-escalation and positive engagement as well as ensuring that the patient is safe_ This level of observation is continuous_ .the observing staff must be present at all times must be constantly alert to the wellbeing of the secluded patient _ and record observations of the patients behaviour and evidence of risks within a maximum period of every 15 minutes. And then this Where a patient in seclusion has been sedated registered nurse should remain in sight and sound of the patient at all times and vital signs should be recorded at regular intervals until assessed by the nurse in and vital signs are normal. they charge
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) The code of Practice for Mental health 1983 sets out at para 15.55
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) alive. Between 15 to 20 minutes later a member of staff looking through the seclusion window noticed that Mr Proverbs was unwell and the alarm was raised The nurse who was responsible for carrying out continuous observations was sitting On a sofa and did not have Mr Proverbs in his sight at the time that he collapsed. An ambulance was called at 19.22 and arrived at the hospital at 19.29 and the ambulance staff reached Mr proverbs at 19.32 Hrs. The Hospital policies in place at that time required continuous observation of a patient in seclusion and this did not happen resulting in Mr Proverbs collapse not being witnessed and as a consequence Mr Proverbs death was contributed to by neglect The use of Clopixol played a more than minimal or trivial contribution to Mr Proverbs death in that it is the most likely of a number of possible causes of the ventricular fibrillation: (End of narrative conclusion) Care at the North London Clinic was provided by Partnerships In Care. There are 3 documents that deal with the question of observation in seclusion and these are firstly the Code of Practice Mental Health Act 1983 Clinical Practice Guidelines Violence The short-term management of disturbed /violent behaviour in in-patient
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) psychiatric settings and emergency departments. 2005/2006 North London Clinic Hospital Policies. It seems to me that the purpose of these policies is to ensure that seclusion is properly used and managed safely. Mr Proverbs was transferred to the North London Clinic on 21st October under Section 48. The use of seclusion was determined using Policy 94 together with other relevant policies and the code of Practice for the Mental Heath Act. Policy 94 which is titled NURSING PATIENTS IN SECLUSION AND LONGER TERM SEGREGATION. The introduction sets out that Nursing patients in seclusion Or in longer term segregation can be complex and require clear guidance to promote good practice within the Partnerships In Care. The policy sets out the context and framework within which Partnerships In Care staff will practice. The policy is to be read in conjunction with Mental Heath Code of Practice England and Wales
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) Partnerships In Care operational policies Safe and Supportive Observations Reviewing of incidents and untoward occurrences Guidelines for the use of rapid tranquilization Health Record and Management Partnerships In Care Operational Policy. The Partnerships In Care policy where under the heading observation the following sets out:- The aim of the observation is to monitor the condition and behaviour of the patient, specifically in relation to the reason for the seclusion and to encourage de-escalation and positive engagement as well as ensuring that the patient is safe_ This level of observation is continuous_ .the observing staff must be present at all times must be constantly alert to the wellbeing of the secluded patient _ and record observations of the patients behaviour and evidence of risks within a maximum period of every 15 minutes. And then this Where a patient in seclusion has been sedated registered nurse should remain in sight and sound of the patient at all times and vital signs should be recorded at regular intervals until assessed by the nurse in and vital signs are normal. they charge
Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) The code of Practice for Mental health 1983 sets out at para 15.55
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.