Neil Challinor-Mooney
PFD Report
All Responded
Ref: 2021-0164
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
All 1 response received
· Deadline: 15 Jul 2021
Response Status
Responses
1 of 1
56-Day Deadline
15 Jul 2021
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
The Inquest heard evidence that the Trust policy in relation to risk assessment and risk management is sufficiently clear; however the Court was not fully satisfied that the policy had been fully embedded into practice. A number of nursing staff, including senior nursing staff, during the course of the admission, failed to follow the policy: Another concern arising during the course of the Inquest related to the integrity of the electronic records. The Inquest heard that medical records should be validated very shortly after entered into the system. The Court saw evidence of multiple entries where there was a significant delay between original entry and validation. Amendments were made to the records after Neil had passed away, but these were not apparent on the records disclosed to the Court. An audit of the records had to be carried out before the amendments were exposed
Responses
Response received
View full response
Dear Miss Persaud
Re: Inquest touching upon the death of Mr Neil Challinor- Mooney
I refer to your letter dated 20 May 2021 and the Regulation 28 report, detailing your concerns in care provided by NELFT NHS Foundation Trust (‘NELFT’).
We have taken the concerns expressed by you very seriously and agreed to take a number of actions in addition to the actions already taken in respect of learning from the very sad death of Mr Challinor- Mooney. We are very grateful to you for your invaluable contribution in improving patient care.
Please find attached action plan detailing the Trust’s efforts to prevent future deaths and to improve the safety and quality of care provided by the Trust.
I hope that the attached action plan conveys our commitment to continuously improve our services, however if you would like to discuss these actions further, please kindly feel free to contact my office on 0300 555 1201.
Re: Inquest touching upon the death of Mr Neil Challinor- Mooney
I refer to your letter dated 20 May 2021 and the Regulation 28 report, detailing your concerns in care provided by NELFT NHS Foundation Trust (‘NELFT’).
We have taken the concerns expressed by you very seriously and agreed to take a number of actions in addition to the actions already taken in respect of learning from the very sad death of Mr Challinor- Mooney. We are very grateful to you for your invaluable contribution in improving patient care.
Please find attached action plan detailing the Trust’s efforts to prevent future deaths and to improve the safety and quality of care provided by the Trust.
I hope that the attached action plan conveys our commitment to continuously improve our services, however if you would like to discuss these actions further, please kindly feel free to contact my office on 0300 555 1201.
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
On the 2gth November 2018 commenced an investigation into the death of Neil Challinor-Mooney, age 51 years_ The investigation concluded at the end of the jury inquest on 12th May 2021. The conclusion of the inquest was that Neil died as a result of suicide contributed to by neglect
Circumstances of the Death
Neil Challinor-Mooney suffered an acute relapse in his mental health in late October 2018, He required admission to hospital under provisions of the Mental Health Act on the 1st November 2018. Shortly after his admission to hospital, his trainers were removed from as part of risk management. There was no documentation around the removal of the trainers_ At some_point during the course of admission to hospital Area the him
November to 16th November 2018) Neils trainers were returned to There was no documentation as to when the trainers were returned or any documentation around risk assessment or risk management relating to the decision to return the trainers ;_ On the 13"n November 2018 Neil disclosed in a ward round that he was having suicidal thoughts and that he would use his shoe laces to hang himself. The risk assessment and risk management plan was not updated as a result of this disclosure Neil repeated this disclosure to a junior psychologist on the 14th November 2018. The psychologist disclosed the suicidal ideation and the plan to the senior nursing team_ An action was documented for Neils shoes to be removed; but this was never carried out On the 16th November 2018 Neil was found suspended by the laces of his trainers He was in an unconscious state. Sadly, he passed away at Queens Hospital on the 18th November
November to 16th November 2018) Neils trainers were returned to There was no documentation as to when the trainers were returned or any documentation around risk assessment or risk management relating to the decision to return the trainers ;_ On the 13"n November 2018 Neil disclosed in a ward round that he was having suicidal thoughts and that he would use his shoe laces to hang himself. The risk assessment and risk management plan was not updated as a result of this disclosure Neil repeated this disclosure to a junior psychologist on the 14th November 2018. The psychologist disclosed the suicidal ideation and the plan to the senior nursing team_ An action was documented for Neils shoes to be removed; but this was never carried out On the 16th November 2018 Neil was found suspended by the laces of his trainers He was in an unconscious state. Sadly, he passed away at Queens Hospital on the 18th November
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.