Archi Johnson
PFD Report
All Responded
Ref: 2022-0231
All 1 response received
· Deadline: 23 Sep 2022
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Response Status
Responses
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56-Day Deadline
23 Sep 2022
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1.Evidence was heard regarding the manner in which information crucial to the formulation of risk assessments was recorded and shared: a)Two types of risk assessments were completed, with no system to ensure that important information is present on both; b) The previous incident in which Archi had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care; c) Those responsible for his care accepted that the above incident was one of which they would have wanted to have knowledge; d) The absence of that information may have affected the subsequent decisions made regarding the setting of risk level, observation level and removal of potentially dangerous ligature items.
Responses
Response received
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Dear Ms Longhorn
Re: Archi Johnson - Inquest 11 May 2022 Regulation 28 Report to Prevent Future Deaths
Thank you for your letter following the inquest into the death of Archi Johnson. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust.
The Trust has undertaken a Serious Incident Investigation following the death of Archi; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.
Your report contained the following matters of concern -
1) Evidence was heard regarding the manner in which information crucial to the formulation of risk assessments was recorded and shared:
a) Two types of risk assessment were completed, with no system to ensure that important information is present in both
b) The previous incident in which Archi had attempted to his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by the staff and therefore not known to a number of those responsible for his care
c) Those responsible for his care accepted that the above incident was one which they would have wanted to have knowledge
d) The absence of that information may have affected the subsequent decisions made regarding the setting of risk level, observation level and removal of potentially dangerous ligature items
We have attached a copy of the actions we have taken or continue to progress to ensure that lessons are learnt from this tragic death. I hope that the actions described demonstrate our commitment to the learning we have undertaken and that the Trust is committed to this
continued positive work within our services. If you require any further information please do not hesitate to contact me.
As you may be aware, the Trust is currently experiencing issues accessing our usual electronic patient record systems and as a result there may be some delays in completing the actions relating to the clinical audit as this will depend on our being able to access the full clinical records. We continue to support people who use our services and the Trust is able to maintain current records using a secure alternative. We are working closely with the software provider to resolve these technical issues and apologise for any delay that may result.
Re: Archi Johnson - Inquest 11 May 2022 Regulation 28 Report to Prevent Future Deaths
Thank you for your letter following the inquest into the death of Archi Johnson. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust.
The Trust has undertaken a Serious Incident Investigation following the death of Archi; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.
Your report contained the following matters of concern -
1) Evidence was heard regarding the manner in which information crucial to the formulation of risk assessments was recorded and shared:
a) Two types of risk assessment were completed, with no system to ensure that important information is present in both
b) The previous incident in which Archi had attempted to his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by the staff and therefore not known to a number of those responsible for his care
c) Those responsible for his care accepted that the above incident was one which they would have wanted to have knowledge
d) The absence of that information may have affected the subsequent decisions made regarding the setting of risk level, observation level and removal of potentially dangerous ligature items
We have attached a copy of the actions we have taken or continue to progress to ensure that lessons are learnt from this tragic death. I hope that the actions described demonstrate our commitment to the learning we have undertaken and that the Trust is committed to this
continued positive work within our services. If you require any further information please do not hesitate to contact me.
As you may be aware, the Trust is currently experiencing issues accessing our usual electronic patient record systems and as a result there may be some delays in completing the actions relating to the clinical audit as this will depend on our being able to access the full clinical records. We continue to support people who use our services and the Trust is able to maintain current records using a secure alternative. We are working closely with the software provider to resolve these technical issues and apologise for any delay that may result.
Report Sections
Investigation and Inquest
On 14th November 2019 I commenced an investigation into the death of Archi Johnson. The investigation concluded at the end of the inquest on 11th May 2022. The conclusion of the inquest was suicide, the medical cause of death being hanging.
Circumstances of the Death
Archi was diagnosed with Schizoaffective Disorder with a history of depression, self-harm and suicidal ideation. On 5th November 2019 Archi was voluntarily admitted into Moorland View at North Devon District Hospital having told mental health professionals that he had intrusive thoughts of taking his own life and he did not feel safe to go home. During an admission on the ward two months earlier, Archi had attempted to take his own life by ligaturing
On admission, Archi’s risk level was assessed as medium and he was placed on Level 1 observations. On 7th November 2019 Archi was found hanging
On admission, Archi’s risk level was assessed as medium and he was placed on Level 1 observations. On 7th November 2019 Archi was found hanging
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.