William Dickens
PFD Report
All Responded
Ref: 2018-0137
All 1 response received
· Deadline: 26 Aug 2018
Response Status
Responses
1 of 1
56-Day Deadline
26 Aug 2018
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
Coroners Concerns
In circumstances it is my statutory duty to report to you _ (1) From 10 am on the morning of 10 May 2017 the observation the ward was not complied with While there arc notes on the observation log suggesting that some patients had been seen in the period between 10 am and 1] am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation shows that several other patients were unaccounted for the same period.
(2) During the inquest the nurse in of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and [ L am were not made contemporaneously but after Mr Dickens had died. No note had been made on the to indicate that the entries were made after the event_ (3) While the observation may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks 0n the patients were in fact conducted; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe_ Those purposes are plainly frustrated if entries are made on the at times that are different to the actual observations; and after the event; Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur; or will continue to exist; in the future_
(2) During the inquest the nurse in of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and [ L am were not made contemporaneously but after Mr Dickens had died. No note had been made on the to indicate that the entries were made after the event_ (3) While the observation may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks 0n the patients were in fact conducted; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe_ Those purposes are plainly frustrated if entries are made on the at times that are different to the actual observations; and after the event; Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur; or will continue to exist; in the future_
Responses
Response received
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Dear Ms Henrietta Hill Re: Prevent future deaths Mr William Dickens This letter responds to the Prevent Future Deaths report issued to South London and Maudsley NHS Foundation Trust on & May 2018 in relation to the death of Mr William Dickens on 10" May 2017 whilst in our care_ In the PFD report you set out five matters of concern that relate to how nurses observed Mr Dickens, how and when the observations were recorded and how effectively observations records are used to maintain the safety of Mr Dickens. You have directed Trust to take action to eliminate or reduce the risk of death created by the Way our nurses carried out and recorded observations for Mr Dickens_ actions we will take are: The Director %f Nursing to use the case a8 the basis of an internal safety alert 'Blue Light Bulletin' to be sent out to all registered nurses to reinforce the practice standards To be completed by 6/07/18
2) All Ward Managers to be directed to have learning conversation with inpatient registered and non-registered nurses about the practice To be completed by 31/07/18
3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to clarity of practice standards and the implementation of the policy: the The the
Underway, to be completed by 31/08/18 From September 2018 the cohort of newly registered nurses to receive a "Learning the Lessons' presentation_ using this case a8 the basis, of the importance of timely observation and recording in preserving safety and confidence in those We care for. Commencing September 2018 and annual thereafter. From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for, Commencing September 2018 and annual thereafter:
6) Report the PFD and the actions taken to the Board of Directors as a part of the quarterly public learning lessons report Completed by November 2018 The Director of Nurslng as Chair of the E-observation Project Group to develop the timeline for transforming mental health safety and engagement observations into e-observation framework This is a long term project that is complex to deliver; a time frame is difficult to reliably commit the aim will be scoping from January 2019.
8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance. Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate: trust that these actions address the five concerns that are set out In section 5 of the preventing further deaths report; am happy to answer further questions or provide further information should that be necessary_
2) All Ward Managers to be directed to have learning conversation with inpatient registered and non-registered nurses about the practice To be completed by 31/07/18
3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to clarity of practice standards and the implementation of the policy: the The the
Underway, to be completed by 31/08/18 From September 2018 the cohort of newly registered nurses to receive a "Learning the Lessons' presentation_ using this case a8 the basis, of the importance of timely observation and recording in preserving safety and confidence in those We care for. Commencing September 2018 and annual thereafter. From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for, Commencing September 2018 and annual thereafter:
6) Report the PFD and the actions taken to the Board of Directors as a part of the quarterly public learning lessons report Completed by November 2018 The Director of Nurslng as Chair of the E-observation Project Group to develop the timeline for transforming mental health safety and engagement observations into e-observation framework This is a long term project that is complex to deliver; a time frame is difficult to reliably commit the aim will be scoping from January 2019.
8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance. Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate: trust that these actions address the five concerns that are set out In section 5 of the preventing further deaths report; am happy to answer further questions or provide further information should that be necessary_
Action Should Be Taken
being the regime for log during charge log being log log
I consider that action should be taken to prevent the occurrence o continuation of such circumstances, or to eliminate Or reduce the risk of death created by such circumstances_ Accordingly, [ am reporting the matter to you as believe you may have the power to take such action.
I consider that action should be taken to prevent the occurrence o continuation of such circumstances, or to eliminate Or reduce the risk of death created by such circumstances_ Accordingly, [ am reporting the matter to you as believe you may have the power to take such action.
Report Sections
Investigation and Inquest
WILLIAM DICKENS, then 77 years, died on 10 2017. An investigation into his death was opened and an inquest held from 1-4 and 8 2017. The medical cause of Mr Dickens' death was hanging: The jury returned a narrative conclusion identifying & range of issues which concluded had contributed to Mr Dickens death:
Circumstances of the Death
The circumstances of the death are as follows: Until late April 2017 Mr Dickens had no issues with his mental health: His family noticed a deterioration in his mental health at that and he was prescribed medication by his GP On 9 2017 Mr Dickens tried to take his own life at his home by wrapping telephone cable around his neck An ambulance was called and he was taken to St Thomas Hospital: When there he was classified as at "high" risk of repeat self-harm and kept 0n one to one observations. (3) He was transferred to the mental health unit for older patients at the Maudsley Hospital, run by SLAM On arrival there he was classified as at 'high" risk of repeat self-harm: aged May May they point May again
Mr Dickens was placed on a regime of intermittent observations which meant he should be seen at varying intervals but at least every 15 minutes. (5) His property was searched and in breach of SLAM policy and recognised process his belt was returned to him. (6) Despite on a regime of intermittent observations, Mr Dickens was not secn from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am-
Mr Dickens was placed on a regime of intermittent observations which meant he should be seen at varying intervals but at least every 15 minutes. (5) His property was searched and in breach of SLAM policy and recognised process his belt was returned to him. (6) Despite on a regime of intermittent observations, Mr Dickens was not secn from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am-
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.