Liam Thomas
PFD Report
All Responded
Ref: 2017-0347
All 1 response received
· Deadline: 2 Apr 2018
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
2 Apr 2018
All responses received
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Source: Courts and Tribunals Judiciary
Coroner's Concerns
the circumstances it is my statutory to make this report to you: in relation to plastic bags/restricted items and, secondly, communications with family: recognise that lessons have already been learnt following Liam's death as set out in the Route Cause Analysis investigation and, specifically, in the action plan. Ms Klink gave further evidence about this_ In relation to the first concern, about plastic bags as restricted items on the ward, the sad fact is that Liam was able to take his own life because he had access to plastic bags. were Sainsbury's bags. He attended Sainsbury's on Section 17 leave two days prior to his death: There was evidence that these bags were taken from him on return to the ward: It could ot be ascertained if this was correct and whether the bags which Liam used were bags which he obtained on the trip to Sainsbury's or whether the bags were obtained in some other way on the ward. understand there have been improvements in the system in relation to plastic bags in particular: appreciate however that the problem of plastic bags is not straight forward, particularly when one takes into account the fact that many patients are informal patients and are free to leave and return and that visitors may also bring plastic bags when visiting: understand that there are clear warnings that plastic are restricted items at the entrance to the ward and that steps are taken to bring this to the attention of visitors: It would be helpful if could be provided with further details about the steps that are in place_ related concern was the environmental searches that were intended, amongst other things, to check for plastic bags. was shown what are referred to as daily environmental safety check lists which include plastic bags/bin liners on them: had the impression from the evidence that, at the time, these checks were not being carried out as regularly as should be. Indeed, see that recommendation 2 on the RCAAction Plan concerns standardising the frequency of environmental checks and monitoring of banned items across all in patient wards_ It states that should be carried out daily. It appears policy is in place and recommendation but it is not clear to me whether there is effective implementation Consequently request that this matter be reviewed and that receive a response specifically about implementation The second area of concern is about communication with family. Again, realise that this is not a straightforward matter because there are issues of consent and it is also the case that some families are not supportive or united: However; in Liam's case, it is clear that his family were very supportive and united in terms of Liam's health and wellbeing: A concern at inquest from the evidence was that there was a need for improved communication in terms of information provided by family to staff and also the staff (particularly concerning elevated risk) to family members This will enable family to be more watchful_ in her evidence , referred to the "triangular approach" and recognised that there was more work to be done in this difficult area; She indicated that work was on going: It would be helpful if you could provide details about the current policy and practice concerning communications with family and if there is a programme in place, to improve it. duty They bags they they from
Responses
Response received
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Dear Mr Salter;, Regulation 28 Report to Prevent Further Deaths following the inquest concerning the death of Ilr Liam Thomas am writing in response to your letter dated 4th September 2017 , and the enclosed Regulation 28 Report to Prevent Further Deaths following the inquest concerning the death of Mr Liam Thomas_ The particular concerns raised you were as follows: Mr Thomas' access to plastic which are a restricted item on the ward.
2. The consistency and standard to which daily environmental checks are carried out.
3. The communication with Mr Thomas' family while he was an inpatient on Phoenix ward. will address these in turn. Concern 1 Plastic bags are a restricted item on all wards. There are posters displaying this in the ward reception areas, and on several points inside the wards. Staff are requested to draw all visitors and patients attention to this and to remove any restricted items before anyone enters the ward environment: Plastic bags are a very common item; and are regularly brought to the ward: Mr Thomas' sad death drew our attention to the fact that there had been an inconsistent approach to managing this across our wards. Some staff were removing the bags at reception; but at other times visitors (especially regular visitors) were asked to take the items to the patient's room and then return the bag to the nursing office, but there was no way of checking if this had been done. Following this incident clear guidance was issued to 20th by bags
all staff that plastic bags must be removed at reception, if this is impractical, staff must accompany the visitor or patient to the patient's room, allow them to remove the items and remove the bag; disposing of it or placing it in patient's locker which can only be accessed under staff supervision. We have added a column to the visitors' signing in book for staff to confirm that all visitors and returning patients have been advised about restricted items and asked to hand over any such items may be bringing on to the ward. Staff will be required to complete this, which will be monitored by matrons weekly by checking the visitor's book, at the same time as the monitoring of environmental checks. In addition, we looked at alternative safe ways for patients and visitors to bring items on to the wards, and ordered paper bags to be available on all wards as an alternative to carrying items in plastic bags. Staff will offer this as an alternative to visitors at the reception area, and for patients who bring back items when enter the ward The advice on restricted items on wards has also been added to the Admission Information packs, and included on the admission check list for staff to complete. Admission checklists are audited by the ward matrons on a monthly basis_ Our carer and family information pack given to families on admission also contains information about restricted items. The distribution of the family information pack is included in the admission check which is monitored monthly by the ward matron Concern 2 Following this sad incident we also became aware that the recording of the daily environmental checks was inconsistent, All staff interviewed were clear that this had to be done a minimum of once daily, and there was evidence that this was consistently allocated at the start of each shift However the recording of it was inconsistent and we therefore did not have sufficient evidence that it had actually been carried out: new standard operating procedure (SOP) for carrying out environmental checks was devised and an example of the form is included at appendix 1_ Matrons are now required to review the checks carried out on weekly basis to ensure consistency in reporting, and ensure that any gaps in recording are addressed directly with staff. Matrons are reporting on their monitoring monthly to the senior matron. In addition we are currently trialing several different versions of the form to ensure that it supports staff fully in carrying out this important task: We expect to make final decision on form to be used by all by end of October 2017. they they list,
Concern 3 The Trust is signed up to the 'Triangle of Care' 6 principles of involving carers, family and friends We were very disappointed to learn that Mr Thomas' family did not feel adequately communicated with during his inpatient admission. This was complicated by the fact that Mr Thomas was unsure about the extent to which he wanted staff to communicate and at times asked staff not to inform his family of how he had presented on the ward. However, we recognise the crucial role families play in a patient's recovery and the importance of ensuring that families feel involved and supported through what is often a very difficult time. The team on Phoenix ward have been facilitated to reflect on this incident, particularly the experience of Mr Thomas's family, and since this incident a lot of work has taken place to improve the support and involvement of carers across adult services_ We have devised a Carer's Handbook (attached at appendix 2) and all wards have 'welcome leaflets' explaining the practical workings of the ward such as visiting times and restricted items. The Carer's Handbook has been devised for use by our community teams as well as inpatient wards, in recognition of that fact that family (or carer) involvement in care is equally important in both settings. There is an expectation that all workers distribute these appropriately as well as them being widely available in outpatient clinics and ward reception areas_ The handbooks are also made available at various Family and Carer events, forums and reference groups which are regularly held locally by teams Staff are regularly reminded to distribute the handbook to patients' friends and family through their monthly business meetings_ We have also employed a full time Patient and Carer Experience lead, who is overseeing the Carer and Family surveys which we CO-designed with carers, and which provide direct feedback to wards and community teams about the experience of carers and families, and gives teams the opportunity to liaise directly with carers about the improvements are making: Earlier this year we introduced a new tool called IWantGreatCare which asks patients and carers a series of questions about their experience of the care they have received and give them opportunity to leave free text feedback This is immediately received by team managers s0 can respond dynamically to concerns raised. The tool is available online and on paper, and we rely on staff on wards and in community teams to ask patients and carers to give feedback, as well as posters and materials in wards and outpatients clinics advertising the feedback tool. In addition our patient and carer engagement lead regularly visits all services to work with managers to ensure plans are in place to address the feedback teams receive and hold open surgeries in wards and outpatient clinics encouraging patients and carers to give feedback. Staff also have an app on their ipads which they can encourage patients and carers to use to give feedback after their contact with them. We monitor the responses by team monthly which is reported in our leadership meetings, and report on patient experience is forwarded to the board of the Trust on a quarterly basis. This allows us to identify teams where feedback is low, and address this on a local basis_ IWantGreatCare also allows people to leave specific comments about individual staff 3 they they
members and request contact from the team manager: Additional concerns note that; in your covering letter to the Regulation 28 report; you also raised queries regarding the processes surrounding the removal and return of risk items from patients, for example at times of heightened risk. Specifically you enquired whether it is recorded when items are removed from or returned to patients Patients may access their secure lockers on frequent basis throughout the day, and are always observed by staff when doing so, recording all items going in and out of lockers would be extremely labour intensive, however when banned items are found and removed from patients this is recorded in their clinical notes_ In addition all patients have individual care plans which detail the care delivered including the management of risk; and therefore any items which are not considered safe for that individual based on their specific risk assessment will be recorded in that plan_ also note your separate letter; dated 4"h September 2017, following your inquest into the sad death of Mr Andrew Crawford, in which you identified concerns regarding communication with family hope that the matters you raised are addressed in this letter; specifically in the section relating to 'Concern 3' above_ acknowledge your intention to share copy of this letter with Mr Crawford's family. In addition to the above; the Trust carried out a Serious Incident (Sl) Investigation which you have already received: An independent outside investigator was appointed to carry this out and the report highlighted number of recommendations which have all now been completed: The above actions as well as those highlighted in the Sl report were taken in order to reduce the risk of this very sad incident happening again: We will continue to monitor our adherence to our policies and standards. hope the information in this letter provides you with reassurance that appropriate action has been taken to improve the safety of our environments and address the issues you helpfully highlighted in your Regulation 28 Report If you require any clarification of further information; do not hesitate to get in touch:
2. The consistency and standard to which daily environmental checks are carried out.
3. The communication with Mr Thomas' family while he was an inpatient on Phoenix ward. will address these in turn. Concern 1 Plastic bags are a restricted item on all wards. There are posters displaying this in the ward reception areas, and on several points inside the wards. Staff are requested to draw all visitors and patients attention to this and to remove any restricted items before anyone enters the ward environment: Plastic bags are a very common item; and are regularly brought to the ward: Mr Thomas' sad death drew our attention to the fact that there had been an inconsistent approach to managing this across our wards. Some staff were removing the bags at reception; but at other times visitors (especially regular visitors) were asked to take the items to the patient's room and then return the bag to the nursing office, but there was no way of checking if this had been done. Following this incident clear guidance was issued to 20th by bags
all staff that plastic bags must be removed at reception, if this is impractical, staff must accompany the visitor or patient to the patient's room, allow them to remove the items and remove the bag; disposing of it or placing it in patient's locker which can only be accessed under staff supervision. We have added a column to the visitors' signing in book for staff to confirm that all visitors and returning patients have been advised about restricted items and asked to hand over any such items may be bringing on to the ward. Staff will be required to complete this, which will be monitored by matrons weekly by checking the visitor's book, at the same time as the monitoring of environmental checks. In addition, we looked at alternative safe ways for patients and visitors to bring items on to the wards, and ordered paper bags to be available on all wards as an alternative to carrying items in plastic bags. Staff will offer this as an alternative to visitors at the reception area, and for patients who bring back items when enter the ward The advice on restricted items on wards has also been added to the Admission Information packs, and included on the admission check list for staff to complete. Admission checklists are audited by the ward matrons on a monthly basis_ Our carer and family information pack given to families on admission also contains information about restricted items. The distribution of the family information pack is included in the admission check which is monitored monthly by the ward matron Concern 2 Following this sad incident we also became aware that the recording of the daily environmental checks was inconsistent, All staff interviewed were clear that this had to be done a minimum of once daily, and there was evidence that this was consistently allocated at the start of each shift However the recording of it was inconsistent and we therefore did not have sufficient evidence that it had actually been carried out: new standard operating procedure (SOP) for carrying out environmental checks was devised and an example of the form is included at appendix 1_ Matrons are now required to review the checks carried out on weekly basis to ensure consistency in reporting, and ensure that any gaps in recording are addressed directly with staff. Matrons are reporting on their monitoring monthly to the senior matron. In addition we are currently trialing several different versions of the form to ensure that it supports staff fully in carrying out this important task: We expect to make final decision on form to be used by all by end of October 2017. they they list,
Concern 3 The Trust is signed up to the 'Triangle of Care' 6 principles of involving carers, family and friends We were very disappointed to learn that Mr Thomas' family did not feel adequately communicated with during his inpatient admission. This was complicated by the fact that Mr Thomas was unsure about the extent to which he wanted staff to communicate and at times asked staff not to inform his family of how he had presented on the ward. However, we recognise the crucial role families play in a patient's recovery and the importance of ensuring that families feel involved and supported through what is often a very difficult time. The team on Phoenix ward have been facilitated to reflect on this incident, particularly the experience of Mr Thomas's family, and since this incident a lot of work has taken place to improve the support and involvement of carers across adult services_ We have devised a Carer's Handbook (attached at appendix 2) and all wards have 'welcome leaflets' explaining the practical workings of the ward such as visiting times and restricted items. The Carer's Handbook has been devised for use by our community teams as well as inpatient wards, in recognition of that fact that family (or carer) involvement in care is equally important in both settings. There is an expectation that all workers distribute these appropriately as well as them being widely available in outpatient clinics and ward reception areas_ The handbooks are also made available at various Family and Carer events, forums and reference groups which are regularly held locally by teams Staff are regularly reminded to distribute the handbook to patients' friends and family through their monthly business meetings_ We have also employed a full time Patient and Carer Experience lead, who is overseeing the Carer and Family surveys which we CO-designed with carers, and which provide direct feedback to wards and community teams about the experience of carers and families, and gives teams the opportunity to liaise directly with carers about the improvements are making: Earlier this year we introduced a new tool called IWantGreatCare which asks patients and carers a series of questions about their experience of the care they have received and give them opportunity to leave free text feedback This is immediately received by team managers s0 can respond dynamically to concerns raised. The tool is available online and on paper, and we rely on staff on wards and in community teams to ask patients and carers to give feedback, as well as posters and materials in wards and outpatients clinics advertising the feedback tool. In addition our patient and carer engagement lead regularly visits all services to work with managers to ensure plans are in place to address the feedback teams receive and hold open surgeries in wards and outpatient clinics encouraging patients and carers to give feedback. Staff also have an app on their ipads which they can encourage patients and carers to use to give feedback after their contact with them. We monitor the responses by team monthly which is reported in our leadership meetings, and report on patient experience is forwarded to the board of the Trust on a quarterly basis. This allows us to identify teams where feedback is low, and address this on a local basis_ IWantGreatCare also allows people to leave specific comments about individual staff 3 they they
members and request contact from the team manager: Additional concerns note that; in your covering letter to the Regulation 28 report; you also raised queries regarding the processes surrounding the removal and return of risk items from patients, for example at times of heightened risk. Specifically you enquired whether it is recorded when items are removed from or returned to patients Patients may access their secure lockers on frequent basis throughout the day, and are always observed by staff when doing so, recording all items going in and out of lockers would be extremely labour intensive, however when banned items are found and removed from patients this is recorded in their clinical notes_ In addition all patients have individual care plans which detail the care delivered including the management of risk; and therefore any items which are not considered safe for that individual based on their specific risk assessment will be recorded in that plan_ also note your separate letter; dated 4"h September 2017, following your inquest into the sad death of Mr Andrew Crawford, in which you identified concerns regarding communication with family hope that the matters you raised are addressed in this letter; specifically in the section relating to 'Concern 3' above_ acknowledge your intention to share copy of this letter with Mr Crawford's family. In addition to the above; the Trust carried out a Serious Incident (Sl) Investigation which you have already received: An independent outside investigator was appointed to carry this out and the report highlighted number of recommendations which have all now been completed: The above actions as well as those highlighted in the Sl report were taken in order to reduce the risk of this very sad incident happening again: We will continue to monitor our adherence to our policies and standards. hope the information in this letter provides you with reassurance that appropriate action has been taken to improve the safety of our environments and address the issues you helpfully highlighted in your Regulation 28 Report If you require any clarification of further information; do not hesitate to get in touch:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
Report Sections
Investigation and Inquest
concluded the inquest into the sad death of Liam Thomas at Oxford Coroner's Court on 28th 2017. Mr Thomas died at Littlemore Hospital Oxford on 28"h August 2016. The jury returned a narrative conclusion as follows: Liam was found in a shower room of the Phoenix Ward of Littlemore Hospital with plastic bags over his head, secured in place with a shoelace, at about 14.00 on the 28"h August 2016, and pronounced dead at 15.21 at the John Radcliffe Hospital the same day: The cause of death was asphyxiation. At this Liam intended to take his own life. This intention was formed at a time when his mind was disturbed and the following inadequacies in the provision of mental health care at Littlemore Hospital contributed to his death: failure to ensure patients safety in relation to a banned item (plastic bags) and failure to manage items identified by staff to be of individual personal risk to Liam (ligature items). There was written and oral evidence at the inquest which included evidence from nursing staff and doctors from the Trust together with Head of Nursing for the Adult Directorate_ The Trust were legally represented at the inquest: A full copy of the inquest file was provided in advance have not therefore provided you with a full copy of the inquest file with this letter_
Circumstances of the Death
The circumstances are briefly set out above in the narrative conclusion: As you will know, Liam was 21 years old when he died on 28 August 2016. CPR was carried out and he was taken to the John Radcliffe Hospital by ambulance but he was pronounced death soon after arrival. He was a single man who lived with his mother and sister in Didcot, He worked in ICT as a Programming Developer: Liam had suffered with mental health problems before his death including thoughts of taking his own life . He was detained under Section 2 of The Mental Health Act 1983 on 11 August 2016 and remained an inpatient on the Phoenix Ward at Littlemore hospital until his sad death_ July time ,
Inquest Conclusion
Liam was found in a shower room of the Phoenix Ward of Littlemore Hospital with plastic bags over his head, secured in place with a shoelace, at about 14.00 on the 28"h August 2016, and pronounced dead at 15.21 at the John Radcliffe Hospital the same day: The cause of death was asphyxiation. At this Liam intended to take his own life. This intention was formed at a time when his mind was disturbed and the following inadequacies in the provision of mental health care at Littlemore Hospital contributed to his death: failure to ensure patients safety in relation to a banned item (plastic bags) and failure to manage items identified by staff to be of individual personal risk to Liam (ligature items). There was written and oral evidence at the inquest which included evidence from nursing staff and doctors from the Trust together with Head of Nursing for the Adult Directorate_ The Trust were legally represented at the inquest: A full copy of the inquest file was provided in advance have not therefore provided you with a full copy of the inquest file with this letter_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.