Darren Hayes
PFD Report
All Responded
Ref: 2014-0538
All 1 response received
· Deadline: 12 Feb 2015
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
12 Feb 2015
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
In the circumstances it is my statutory duty (o report to you: (1) Attempts to contact Mr Hayes by telephone were not documented nor escalated to a senior worker _ it is understood NCC have taken steps to ensure that staff are aware that all calls (even those where there is no response are documented) and a senior member of staff is made aware; (2) The time taken to contact Mr Hayes in the light of the information provided and the risks with which Mr Hayes was presenting-The initial referral to the ECCT was on 10.3.2014, he was allocated for initial assessment which was due to take place on 28.3.14; 3 weeks later. The first attempt to telephone Mr Hayes was on 1.4.2014. A letter was sent to Mr Hayes and on receiving no response, there was no further attempt to contact Mr Hayes until 16.4.2014, almost 5 weeks after both the initial referral and his death_ (3) The risks with which Mr Hayes were not fully considered ie his diabetes being "out of control" , weighing less than 7 stone, lacking motivation, strugg to manage at home_ living alone and having no cooker He was no longer receiving 3 daily visits from NFRS. The evidence was that Mr Hayes had a microwave and could make himself a hot drink".
(3) Despite getting no response to telephone calls or letter; SW did not contact GP, District Nurse or Red Cross (who had discharged him)
(3) Despite getting no response to telephone calls or letter; SW did not contact GP, District Nurse or Red Cross (who had discharged him)
Responses
Response received
View full response
Dear Madam Response on behalf of Norfolk County Council to Regulation 28 Report to Prevent Future Deaths dated 17 December 2014 Darren Hayes Deceased (1) Attempts to contact Mr Hayes by telephone were not documented nor escalated to a senior worker it is understood NCC taken steps to ensure Ihat staff are aware that all calls (even where there is no response are documented) and & senior member of stalf is made aware; Action has been taken in respect of the individual worker and the Adult Social Services Qualily Assurance Team is developing a Best Practice factsheet with Operational Managers setting out the actions to be taken when are unable to make contact with a person who has been referred to the Service. The intention is to formalise local custom and practice for wider use across the Service and set out clearly the conditions for escalation to senior management. The factsheet will also be aimed at identifying other people, including professionals, involved with the person concerned, and promoting good communication. (2) The time taken to contact Mr Hayes in the light of information provided and the risks with which Mr Hayes was presenting: The initial reterral t0 the ECCT was on 10.3.2014, he was allocated for initial assessment which was due to take placed on 28.3.14, 3 weeks later: The first attempt to telephone Mr Hayes was 0n 1.4.14. A letter was sent to Mr Hayes and on receiving no response, there was no further attempt t0 contact Mr Hayes until 16.4.14 almost 5 weeks after both the initial referral and his death www_norfolk gov.uk LYIESTOR LY PEOPLL Your have they
confirm a review of the Duty Operational Instructions is already in progress, and the Coroner's concerns will be built into this work: It is recognised that local custom and practice need to be formalised so that information about risk set out in the referrals is properly taken into account in determining when initial contact is made with people who have been referred to the Service. The Quality Assurance team are reviewing current guidance regarding the way in which such referrals are prioritised: (3) The risks with which Mr Hayes were not fully considered ie his diabetes being "out of control"; weighing less than 7 stone, lacking motivation, struggling to cope at home; alone and having no cooker: He was no longer receiving 3 daily visits from NFRS. The evidence was that Mr Hayes had a microwave and could make himself "a hot drink" As above, | confirm work is being done by the Quality Assurance team to review the current guidance which determines referrals are prioritised once they are received by the locality teams and this will include a review of how individual risks are identified and assessed_ Despite getting no response to telephone calls or letter, SW did not contact GP, District Nurse or Red Cross (who had discharged him) We will ensure that this is fully taken into account in the factsheet referred to in the response to (1) above_ trust this addresses your concerns
confirm a review of the Duty Operational Instructions is already in progress, and the Coroner's concerns will be built into this work: It is recognised that local custom and practice need to be formalised so that information about risk set out in the referrals is properly taken into account in determining when initial contact is made with people who have been referred to the Service. The Quality Assurance team are reviewing current guidance regarding the way in which such referrals are prioritised: (3) The risks with which Mr Hayes were not fully considered ie his diabetes being "out of control"; weighing less than 7 stone, lacking motivation, struggling to cope at home; alone and having no cooker: He was no longer receiving 3 daily visits from NFRS. The evidence was that Mr Hayes had a microwave and could make himself "a hot drink" As above, | confirm work is being done by the Quality Assurance team to review the current guidance which determines referrals are prioritised once they are received by the locality teams and this will include a review of how individual risks are identified and assessed_ Despite getting no response to telephone calls or letter, SW did not contact GP, District Nurse or Red Cross (who had discharged him) We will ensure that this is fully taken into account in the factsheet referred to in the response to (1) above_ trust this addresses your concerns
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisalion have the power to take such action . said buy Day lling
Report Sections
Investigation and Inquest
On 12 March 2014 commenced an invesligation into the death of DARREN HAYES, Age 48 years_ The investigation concluded at the end of Ihe inquest on 11 December 2014. The conclusion of the inquest was medical cause of death: 1a) Poisoning by morphine and benzodiazepines 2 Empyema of the gallbladder and short-form conclusion: Drug Related Death
Circumstances of the Death
Mr Hayes had a number of physical health problems for which he was prescribed a large number of medications He had a long history of opiate dependence and alcohol abuse: From January 2014 he was noted t0 be not eating and losing weight He was not supposed to be drinking alcohol due to chronic pancreatitis but continued to do so. He was referred to Adult Social Care; Norfolk County Council (NCC) on 10.01.14 on discharge from James Paget University Hospital (JPUH) by Norfolk Recovery Partnership, and by Support Worker, Stonham Housing; as he had could not eat or prepare meals properly, struggled with personal care, his weight was under 7 stone, lived alone and had no cooker: was arranged he would receive care in his home 3 times per from Norfolk First Response Service. He also received assistance from the Red Cross_ On 16.01.2014 he was readmitted to JPUH following a fall and discharged 17.1.2014. He again went to JPUH on 18.1.2014. day
He was readmitted to JPUH on 10.2.2014 with severe dehydration, lack of nutrition and confusion Norfolk First Response Service (NFRS) discharged him as he was staying in JPUH: He was discharged home on 18.2.2014. A full Community Care Assessment was not completed by a Social Worker as Mr Hayes said he could manage: He he was considering referral for rehousing to include more support: He agreed to a possible referral to a Day Centre The Social Worker had no concerns as to his mental capacity. The Social Worker believed he had a District Nurse visiting regularly (daily?) and he was receiving assistance from the Red Cross. On 26.2.2014 The Red Cross discharged him from their service as he wanted them to him alcohol. On 27.2.2014 The Social Worker arranged for Mr Hayes to be assessed for a possible Centre_ He was telephoned on 27.2.14,28.2.14, 3.3.14, 4.3.14 and 5.3.14 with no response: On 6.3.14 he was spoken to and agreed to a face to face assessment and was referred to the Eastern Community Care Team (ECCT) on 10.3.14 with the same information as provided on his discharge from JPUH on 10.1.14. He was allocated for assessment on Friday 28.3.2014, which was due to take place on Monday 31.3.2014. Sadly, Mr Hayes died in the meantime on 11.3.2014, before the assessment could take place. ECCT continued to try t conlact Mr Hayes by telephone .On 1.4.2014,a letter was sent out and (hen further attempts to contact Mr Hayes by telephone o 16.4.2014, when the Team was advised Mr Hayes had died
He was readmitted to JPUH on 10.2.2014 with severe dehydration, lack of nutrition and confusion Norfolk First Response Service (NFRS) discharged him as he was staying in JPUH: He was discharged home on 18.2.2014. A full Community Care Assessment was not completed by a Social Worker as Mr Hayes said he could manage: He he was considering referral for rehousing to include more support: He agreed to a possible referral to a Day Centre The Social Worker had no concerns as to his mental capacity. The Social Worker believed he had a District Nurse visiting regularly (daily?) and he was receiving assistance from the Red Cross. On 26.2.2014 The Red Cross discharged him from their service as he wanted them to him alcohol. On 27.2.2014 The Social Worker arranged for Mr Hayes to be assessed for a possible Centre_ He was telephoned on 27.2.14,28.2.14, 3.3.14, 4.3.14 and 5.3.14 with no response: On 6.3.14 he was spoken to and agreed to a face to face assessment and was referred to the Eastern Community Care Team (ECCT) on 10.3.14 with the same information as provided on his discharge from JPUH on 10.1.14. He was allocated for assessment on Friday 28.3.2014, which was due to take place on Monday 31.3.2014. Sadly, Mr Hayes died in the meantime on 11.3.2014, before the assessment could take place. ECCT continued to try t conlact Mr Hayes by telephone .On 1.4.2014,a letter was sent out and (hen further attempts to contact Mr Hayes by telephone o 16.4.2014, when the Team was advised Mr Hayes had died
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.