Paz Ogbe-Millar
PFD Report
All Responded
Ref: 2024-0060
All 1 response received
· Deadline: 1 Apr 2024
Response Status
Responses
1 of 1
56-Day Deadline
1 Apr 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns AI summary
Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Responses
Response received
View full response
Dear Mr Murphy
Re: Regulation 28 report to prevent future deaths
I am writing to you in my capacity as Chief Executive of West Hertfordshire Teaching Hospitals NHS Trust (WHTNH) in response to the concerns you raised following the investigation into the death of Mr Paz Ogbe-Millar, which prompted your Regulation 28 report dated 5 February 2024.
The concerns brought to our attention include:
a) There was confusion among Emergency Department staff at WHTNH regarding the appropriate level of observation for mental health patients awaiting assessment by the Mental Health Liaison Team operated by HPUNFT. This confusion stemmed from inconsistencies between WHTNH's Standing Operating Procedure titled "Management of Mental Health Patients in the Emergency Department (ED) at Watford General Hospital (WGH): Standard Operating Procedure (‘SOP’), Issue date August 2021” and WHTNH’s Emergency Department Adult Mental Health Proforma” Version 3, which lacked a clear guidance on observation levels.
b) The SOP mentions the need for close observation of patients at moderate or high risk of self-harm, with continuous documentation, while the EDP suggests only a 15-minute observation for patients at a medium risk level.
c) Noting the discrepancy, it is evident that mental health patients at medium risk may not be receiving the appropriate level of observation required for their safety.
We have collaborated with the Royal Free London NHS Foundation Trust to refine our assessment tools for patients with mental health needs, ensuring accurate identification of the appropriate level of observation. Consequently, the previously used proforma has been replaced by an electronic assessment which aligns with the current SOP, eliminating any inconsistencies between the two documents.
We are committed to enhancing the care provided to patients with mental health needs awaiting assessment in the Emergency Department. The actions we are undertaking are aimed at improving patient safety and ensuring that incidents like this do not recur. These include the following:
North London Coroner’s Service Barnet, Brent, Enfield, Haringey and Harrow, Barnet Coroner’s Court 29 Wood Street London EN5 4BE
westhertshospitals.nhs.uk
- The Patient Safety Incident Response Plan (PSIRP) and PSIRF Policy have been approved for implementation, focusing on key themes including mental health, which will be reflected in our Quality Account Priorities. (Completed Jan 2024)
- Implementation of an electronic patient record system to improve access to patient information and refine assessment tools for mental health patients. (Completed Nov 2021)
- Recruitment of a Matron for Mental Health to elevate the quality of care. (due to be completed by the end of April 2024).
- Collaboration with Mental Health partnership teams to implement a Suicide Prevention Pathway Pilot is underway.
- Policy updates and a planned mental health awareness week (May 2024) to set expectations for staff. We would once again like to pass on our deepest condolences to Mr Ogbe-Millar's family for their loss.
As a Trust, we have a deep commitment to patient safety and keep our policies and processes under regular review, The action we have taken reflects our culture of continuous improvement and of learning in order to further enhance patient care.
Please feel free to get in touch if you require further clarification.
Re: Regulation 28 report to prevent future deaths
I am writing to you in my capacity as Chief Executive of West Hertfordshire Teaching Hospitals NHS Trust (WHTNH) in response to the concerns you raised following the investigation into the death of Mr Paz Ogbe-Millar, which prompted your Regulation 28 report dated 5 February 2024.
The concerns brought to our attention include:
a) There was confusion among Emergency Department staff at WHTNH regarding the appropriate level of observation for mental health patients awaiting assessment by the Mental Health Liaison Team operated by HPUNFT. This confusion stemmed from inconsistencies between WHTNH's Standing Operating Procedure titled "Management of Mental Health Patients in the Emergency Department (ED) at Watford General Hospital (WGH): Standard Operating Procedure (‘SOP’), Issue date August 2021” and WHTNH’s Emergency Department Adult Mental Health Proforma” Version 3, which lacked a clear guidance on observation levels.
b) The SOP mentions the need for close observation of patients at moderate or high risk of self-harm, with continuous documentation, while the EDP suggests only a 15-minute observation for patients at a medium risk level.
c) Noting the discrepancy, it is evident that mental health patients at medium risk may not be receiving the appropriate level of observation required for their safety.
We have collaborated with the Royal Free London NHS Foundation Trust to refine our assessment tools for patients with mental health needs, ensuring accurate identification of the appropriate level of observation. Consequently, the previously used proforma has been replaced by an electronic assessment which aligns with the current SOP, eliminating any inconsistencies between the two documents.
We are committed to enhancing the care provided to patients with mental health needs awaiting assessment in the Emergency Department. The actions we are undertaking are aimed at improving patient safety and ensuring that incidents like this do not recur. These include the following:
North London Coroner’s Service Barnet, Brent, Enfield, Haringey and Harrow, Barnet Coroner’s Court 29 Wood Street London EN5 4BE
westhertshospitals.nhs.uk
- The Patient Safety Incident Response Plan (PSIRP) and PSIRF Policy have been approved for implementation, focusing on key themes including mental health, which will be reflected in our Quality Account Priorities. (Completed Jan 2024)
- Implementation of an electronic patient record system to improve access to patient information and refine assessment tools for mental health patients. (Completed Nov 2021)
- Recruitment of a Matron for Mental Health to elevate the quality of care. (due to be completed by the end of April 2024).
- Collaboration with Mental Health partnership teams to implement a Suicide Prevention Pathway Pilot is underway.
- Policy updates and a planned mental health awareness week (May 2024) to set expectations for staff. We would once again like to pass on our deepest condolences to Mr Ogbe-Millar's family for their loss.
As a Trust, we have a deep commitment to patient safety and keep our policies and processes under regular review, The action we have taken reflects our culture of continuous improvement and of learning in order to further enhance patient care.
Please feel free to get in touch if you require further clarification.
Action Should Be Taken
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Report Sections
Circumstances of the Death
Mr Ogbe-Millar died on 2 December 2021, He was 30 years old and described by his mother as highly intelligent, articulate , charming and well read. For much of his life Mr Ogbe-Millar was a heavy cannabis user; which led to his diagnosis with cannabis induced psychosis in 2020. Mr Ogbe-Millar received treatment from community and in-patient mental health teams at various stages, including two hospital admissions under the Mental Health Act 1983 in late 2020 and in early 2021. On being discharged from hospital in March 2021 he enjoyed & period free of cannabis and psychosis_ He was able to work, attend Narcotics Anonymous and come off his medication. This led to his discharge from the community mental health team in June 2021. In November 2021 Mr Ogbe-Millar gave up his job and resumed using cannabis on a daily basis leading to a relapse of his mental illness_ His mother sought help from the community mental health team who spoke to Mr Ogbe-Millar by telephone on 26 November 2021 and referred him to a substance abuse organisation, which did not specialise in psychosis He was discharged by the community health team on 30 November 2021, without the team having obtained any information regarding his relapse from his mother In the early hours of 2 December 2021 Mr Ogbe-Millar sent a text message to his mother saying: "Im sorry for my actions and hope you all find peace" . His mother immediately telephoned the police who found Mr Ogbe-Millar at home The police took Mr Ogbe-Millar to the Emergency Department of Watford General Hospital, which is operated by West Hertfordshire Teaching Hospitals NHS Trust (WHTHNT ) where there was an inadequate system for recording the information provided by the police to the hospital concerning his risk of self-harm . Mr Ogbe-Millar was assessed by hospital staff later that morning as & moderate risk of self-harm and told to await the arrival of the local Mental Health Liaison Team, which is operated by the Hertfordshire Partnership University NHS Foundation Trust (HPUNFT') Despite Mr Ogbe-Millar'$ risk of self-harm and the protective factor provided by the presence of his mother, she was not allowed to stay with him at the Emergency Department while he waited for the Mental Health Liaison Team: Instead, she was required to leave by staff in breach of hospital policy. The Mental Health Liaison Team had not arrived to assess Mr Ogbe-Millar by the time his mother was required to leave the hospital due t0 problems surrounding the referral system. Soon after his mother had been required to leave_ Mr Ogbe-Millar left the Emergency Department unaccompanied saying he was going outside t0 smoke cigarette . He never returned and instead travelled to London, where he died after jumping in front of a high speed train at Harrow and Wealdstone train station at 10.O9pm on 2 December 2021 .
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.