Harry Vass
PFD Report
All Responded
Ref: 2024-0324
All 1 response received
· Deadline: 8 Aug 2024
Coroner's Concerns (AI summary)
Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is a medical emergency, leading to missed physical health assessments.
View full coroner's concerns
• Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health.
• It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.
• The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.”
• It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.
• The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.”
Responses
Noted
The RCN acknowledges the report and highlights its learning resources for nurses and the importance of safe staffing levels, referring to external reports and standards, but does not comment on the performance of individual nurses or actions it will take. (AI summary)
The RCN acknowledges the report and highlights its learning resources for nurses and the importance of safe staffing levels, referring to external reports and standards, but does not comment on the performance of individual nurses or actions it will take. (AI summary)
View full response
Dear Sirs
Dear Ms Voisin
Prevention of Future Deaths Report – Harry Roland Ian VASS
We respond to your Prevention of Future Deaths (PFD) Report dated 13 June 2024 following the sad death of Harry Vass.
With a membership of over half a million registered nurses, midwives, health visitors, nursing students, nursing support workers, nursing associates and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world.
RCN members work in various hospital and community settings in the NHS, the independent sector and in the education sector. The RCN promotes patient and nursing interests on numerous issues by working closely with the Government, the UK parliaments and other national and worldwide political institutions, trade unions, professional bodies, and voluntary organisations.
Not all registered nurses, midwives, health visitors, nursing students, nursing support workers and nurse cadets are members of the RCN. The Nursing and Midwifery Council (NMC) is the independent regulator for registered nurses and midwives in the UK and nursing associates in the UK. The NMC’s register shows who can practise as a nurse or midwife in the UK or as a nursing associate in England.
Royal College of Nursing 20 Cavendish Square London W1G 0RN Lynn Woolsey Deputy Chief Nurse Telephone:
Email:
The RCN offers a suite of learning resources to support nurses, students, nursing support workers, midwives, and health care professionals at all stages of their careers. We provide expert-led, quality- assured evidence-based education for CPD and learning on a range of topics and subjects.
It is not for the RCN to comment on the performance of any individual nurse or nursing associate.
We note the Matters of Concern set out in PFD as:
I. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency. II. Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health. III. The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters”.
We will respond, as far as we are able to each concern in turn:
I. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.
In situations where ABD (Agitated or Aggressive Behaviour Disturbance) is observed, it is important to note that this describes a person's behaviour and not a specific diagnosis. However, there are limited clear guidelines on the necessary observations in such cases. The Royal College of Psychiatrists has published a position statement regarding (‘ABD’) and ‘excited delirium’ (‘ExD’), emphasising multi-professional and cross-service collaborative working.1 It concludes:
“Staff working in mental health services, including psychiatrists, manage extremely agitated and distressed patients on a daily basis across crisis, liaison, addictions, forensic and psychiatric intensive care services. Joint protocols and more robust training should be in place across services to ensure the care received by patients who are severely agitated and distressed is truly multi-disciplinary.”
When someone presents with agitated behavioural challenges (as described by ABD), traditionally, emergency department staff rule out physical health reasons before contacting psychiatric services. This includes examinations such as infection indicators, CT scans for head injury, and drug screening, terming the phrase ‘medically fit’.
However, such terms do not safeguard against diagnostic overshadowing or missed medical diagnosis and risk giving false reassurance in place of an adequate clinical history, physical examination and
1 https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/position- statements/ps02 22.pdf
investigations as indicated.2 In such circumstances where a patient is classed as ‘medically fit’, mental health nurses in secondary services may be less likely to consider further agitated behaviours as physical health-related.
II. Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health.
III. The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters”.
The RCN cannot comment on the specific factors in the emergency department or the Mason Unit that may have contributed to Harry’s tragic passing.
We agree with Mr Delaney’s statement. However, as stated above, ABD is neither a formal diagnosis nor explicitly embedded in nurses' proficiencies for professional practice.3 The only inferred related proficiency could be:
“4.10 demonstrate the knowledge and ability to respond proactively and promptly to signs of deterioration or distress in mental, physical, cognitive and behavioural health and use this knowledge to make sound clinical decisions.”
However, this standard does not adequately encompass the specific complexities as described by ABD. Although now a legacy statement, it was indirectly in the 2014 field-specific competencies as:
“Acts autonomously and appropriately when faced with sudden deterioration in people's physical or psychological condition or emergency situation, abnormal vital signs, collapse, cardiac arrest, dehydration, self-harm, extremely challenging behaviour, or attempted suicide. OAC9,20.” toc-14-blueprint---mental- health-nursing.pdf (nmc.org.uk)
According to the NICE guideline (NG10, 2015), physical observations should be conducted after the administration of rapid tranquilisation regardless of the causes of agitation. However, the impact and interactions of recreational drugs in this scenario are not well understood. In the absence of evidence, nurses and other medical staff may make professional judgments of evidence in clinical decision-making.
Beyond calls and actions at the individual or micro-level, such as awareness, education and training, broader systemic and cultural considerations are necessary. Staffing levels, skill mix within the team, clinical and policy governance, procedures, escalation plans, raising concerns, management of deteriorating patients, patient safety reviews, and how organisational learning is undertaken following mortality and morbidity reviews must be actioned.
2 https://www.rcpsych.ac.uk/docs/default-source/members/faculties/liaison-psychiatry/liaison-sidebyside.pdf 3 https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-nurses/
According to the NMC annual report4, 27,168 people left the register in the last year, slightly fewer than the previous year. Of those who left, 20.3% (5,508) were nursing and midwifery professionals who left within the first ten years of starting their careers. This percentage has increased for the third consecutive year, up from 18.8% in 2020-2021. Additionally, 49% of those who completed the leavers survey indicated leaving their profession earlier than expected. Nursing staffing levels directly impact patient safety. We can’t improve one without improving the other. The RCN’s Nursing Workforce Standards are a roadmap for designing a workforce that can offer patients high-quality care.5
Many nurses are caring for too many numbers of patients and facing overwhelming pressure and burnout. The correct number of nursing staff with the right skills must be in the right place at the right time.6 A 2024 report by the University of Bath identifies psychological stress, workload, staff shortages, and pay as the top reasons for staff leaving the NHS. Rising burnout symptoms, declining job satisfaction, and low confidence in improving working conditions were also observed. Additionally, the proportion of NHS nurses recommending working for the NHS to others has significantly decreased, highlighting significant retention concerns.7
We hope you find these comments helpful.
Dear Ms Voisin
Prevention of Future Deaths Report – Harry Roland Ian VASS
We respond to your Prevention of Future Deaths (PFD) Report dated 13 June 2024 following the sad death of Harry Vass.
With a membership of over half a million registered nurses, midwives, health visitors, nursing students, nursing support workers, nursing associates and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world.
RCN members work in various hospital and community settings in the NHS, the independent sector and in the education sector. The RCN promotes patient and nursing interests on numerous issues by working closely with the Government, the UK parliaments and other national and worldwide political institutions, trade unions, professional bodies, and voluntary organisations.
Not all registered nurses, midwives, health visitors, nursing students, nursing support workers and nurse cadets are members of the RCN. The Nursing and Midwifery Council (NMC) is the independent regulator for registered nurses and midwives in the UK and nursing associates in the UK. The NMC’s register shows who can practise as a nurse or midwife in the UK or as a nursing associate in England.
Royal College of Nursing 20 Cavendish Square London W1G 0RN Lynn Woolsey Deputy Chief Nurse Telephone:
Email:
The RCN offers a suite of learning resources to support nurses, students, nursing support workers, midwives, and health care professionals at all stages of their careers. We provide expert-led, quality- assured evidence-based education for CPD and learning on a range of topics and subjects.
It is not for the RCN to comment on the performance of any individual nurse or nursing associate.
We note the Matters of Concern set out in PFD as:
I. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency. II. Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health. III. The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters”.
We will respond, as far as we are able to each concern in turn:
I. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.
In situations where ABD (Agitated or Aggressive Behaviour Disturbance) is observed, it is important to note that this describes a person's behaviour and not a specific diagnosis. However, there are limited clear guidelines on the necessary observations in such cases. The Royal College of Psychiatrists has published a position statement regarding (‘ABD’) and ‘excited delirium’ (‘ExD’), emphasising multi-professional and cross-service collaborative working.1 It concludes:
“Staff working in mental health services, including psychiatrists, manage extremely agitated and distressed patients on a daily basis across crisis, liaison, addictions, forensic and psychiatric intensive care services. Joint protocols and more robust training should be in place across services to ensure the care received by patients who are severely agitated and distressed is truly multi-disciplinary.”
When someone presents with agitated behavioural challenges (as described by ABD), traditionally, emergency department staff rule out physical health reasons before contacting psychiatric services. This includes examinations such as infection indicators, CT scans for head injury, and drug screening, terming the phrase ‘medically fit’.
However, such terms do not safeguard against diagnostic overshadowing or missed medical diagnosis and risk giving false reassurance in place of an adequate clinical history, physical examination and
1 https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/position- statements/ps02 22.pdf
investigations as indicated.2 In such circumstances where a patient is classed as ‘medically fit’, mental health nurses in secondary services may be less likely to consider further agitated behaviours as physical health-related.
II. Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health.
III. The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters”.
The RCN cannot comment on the specific factors in the emergency department or the Mason Unit that may have contributed to Harry’s tragic passing.
We agree with Mr Delaney’s statement. However, as stated above, ABD is neither a formal diagnosis nor explicitly embedded in nurses' proficiencies for professional practice.3 The only inferred related proficiency could be:
“4.10 demonstrate the knowledge and ability to respond proactively and promptly to signs of deterioration or distress in mental, physical, cognitive and behavioural health and use this knowledge to make sound clinical decisions.”
However, this standard does not adequately encompass the specific complexities as described by ABD. Although now a legacy statement, it was indirectly in the 2014 field-specific competencies as:
“Acts autonomously and appropriately when faced with sudden deterioration in people's physical or psychological condition or emergency situation, abnormal vital signs, collapse, cardiac arrest, dehydration, self-harm, extremely challenging behaviour, or attempted suicide. OAC9,20.” toc-14-blueprint---mental- health-nursing.pdf (nmc.org.uk)
According to the NICE guideline (NG10, 2015), physical observations should be conducted after the administration of rapid tranquilisation regardless of the causes of agitation. However, the impact and interactions of recreational drugs in this scenario are not well understood. In the absence of evidence, nurses and other medical staff may make professional judgments of evidence in clinical decision-making.
Beyond calls and actions at the individual or micro-level, such as awareness, education and training, broader systemic and cultural considerations are necessary. Staffing levels, skill mix within the team, clinical and policy governance, procedures, escalation plans, raising concerns, management of deteriorating patients, patient safety reviews, and how organisational learning is undertaken following mortality and morbidity reviews must be actioned.
2 https://www.rcpsych.ac.uk/docs/default-source/members/faculties/liaison-psychiatry/liaison-sidebyside.pdf 3 https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-nurses/
According to the NMC annual report4, 27,168 people left the register in the last year, slightly fewer than the previous year. Of those who left, 20.3% (5,508) were nursing and midwifery professionals who left within the first ten years of starting their careers. This percentage has increased for the third consecutive year, up from 18.8% in 2020-2021. Additionally, 49% of those who completed the leavers survey indicated leaving their profession earlier than expected. Nursing staffing levels directly impact patient safety. We can’t improve one without improving the other. The RCN’s Nursing Workforce Standards are a roadmap for designing a workforce that can offer patients high-quality care.5
Many nurses are caring for too many numbers of patients and facing overwhelming pressure and burnout. The correct number of nursing staff with the right skills must be in the right place at the right time.6 A 2024 report by the University of Bath identifies psychological stress, workload, staff shortages, and pay as the top reasons for staff leaving the NHS. Rising burnout symptoms, declining job satisfaction, and low confidence in improving working conditions were also observed. Additionally, the proportion of NHS nurses recommending working for the NHS to others has significantly decreased, highlighting significant retention concerns.7
We hope you find these comments helpful.
Sent To
- Royal College of Nursing
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Aug 2024
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
Report Sections
Investigation and Inquest
On 17/1/23 an investigation was commenced into the death of Harry Roland Ian Vass. The investigation concluded at the end of the inquest 3-13 June 2024. The conclusion of the jury inquest was a narrative which read as follows:
“On the basis of the evidence presented concerning the events of the morning of 26th December 2022, it is probable that the failure to act at that time contributed to the death of Harry, by delaying his transfer to a hospital environment or place of safety.
In relation to Harry's medical treatment in the Emergency Department of Southmead Hospital, prior to his transfer to the Mason Unit, the medical evidence deemed him to be medically fit for discharge, at that time. However, it is probable that the failure to take more physical observations, specifically after he had ingested more cocaine and prescribed medication, significantly contributed to the death in that the evidence for his discharge was more likely than not to have been insufficient.
Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com
Given the evidence regarding his treatment in the Mason Unit, it is probable that the failure to perform adequate observations, both physical and non-contact, contributed to Harry's death as, by failing to prioritise the accurate monitoring of his physical condition and therefore identify it's deterioration, an opportunity to transfer him promptly back into the Emergency Department was missed.”
The medical cause of death was recorded as: 1a) Sudden death, most likely as a result of terminal cardiac arrhythmia, on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology
“On the basis of the evidence presented concerning the events of the morning of 26th December 2022, it is probable that the failure to act at that time contributed to the death of Harry, by delaying his transfer to a hospital environment or place of safety.
In relation to Harry's medical treatment in the Emergency Department of Southmead Hospital, prior to his transfer to the Mason Unit, the medical evidence deemed him to be medically fit for discharge, at that time. However, it is probable that the failure to take more physical observations, specifically after he had ingested more cocaine and prescribed medication, significantly contributed to the death in that the evidence for his discharge was more likely than not to have been insufficient.
Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com
Given the evidence regarding his treatment in the Mason Unit, it is probable that the failure to perform adequate observations, both physical and non-contact, contributed to Harry's death as, by failing to prioritise the accurate monitoring of his physical condition and therefore identify it's deterioration, an opportunity to transfer him promptly back into the Emergency Department was missed.”
The medical cause of death was recorded as: 1a) Sudden death, most likely as a result of terminal cardiac arrhythmia, on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology
Circumstances of the Death
Harry Vass was a 24yr old, he had a history of ADHD, poor mental health, psychosis, paranoia secondary to recreational drug use and illicit drug dependency including cocaine.
Harry attended the A&E department of Southmead Hospital on 26th December 2022 at 16.42hrs, with the reason recorded as “mental health”, he was expressing paranoid thoughts. He had a high heart rate and was sweating. He underwent a physical assessment and was assessed by the Mental Health Team.
At some point he took cocaine in the toilet of the hospital after which he became more agitated and there were concerns being raised that others in the department felt threatened. At one point he absconded from the unit but was brought back, a doctor in the emergency department gave him medication to calm him down. The police were called but when they attended Harry was calm from the effects of the medication.
The police were called and attended again when Harry’s agitation increased. It was during this discussion that the police officer raised the possibility of Harry having ABD (acute behavioural disturbance). The police officer said that he’d seen close to a dozen cases, that Harry had similar symptoms.
The two mental health practitioners said that they knew very little about ABD. After some discussions with the police officer, the two mental health practitioners and the consultant in emergency medicine Harry was deemed medically fit and he was admitted under s136 Mental Health Act to The Mason Unit (a place of safety) within the hospital at around 23.00hrs.
Once on the Mason Unit Harry continued to be distressed and agitated, he was given further medication to calm him. Harry remained disturbed but had periods of calm, he became fearful of isolation, he became sleepy and at around 3.30hrs on 27th December 2022, he vomited. Observations were carried out confirming that Harry had low oxygen saturations and a high temperature. At 4.45hrs his extremities were discolouring, and he became unresponsive, an ambulance was called. He was transferred back to the A&E department but died at 06.36hrs.
Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com
Dr Delaney a forensic pathologist assisted in determining the medical cause of death (noted above).
Harry attended the A&E department of Southmead Hospital on 26th December 2022 at 16.42hrs, with the reason recorded as “mental health”, he was expressing paranoid thoughts. He had a high heart rate and was sweating. He underwent a physical assessment and was assessed by the Mental Health Team.
At some point he took cocaine in the toilet of the hospital after which he became more agitated and there were concerns being raised that others in the department felt threatened. At one point he absconded from the unit but was brought back, a doctor in the emergency department gave him medication to calm him down. The police were called but when they attended Harry was calm from the effects of the medication.
The police were called and attended again when Harry’s agitation increased. It was during this discussion that the police officer raised the possibility of Harry having ABD (acute behavioural disturbance). The police officer said that he’d seen close to a dozen cases, that Harry had similar symptoms.
The two mental health practitioners said that they knew very little about ABD. After some discussions with the police officer, the two mental health practitioners and the consultant in emergency medicine Harry was deemed medically fit and he was admitted under s136 Mental Health Act to The Mason Unit (a place of safety) within the hospital at around 23.00hrs.
Once on the Mason Unit Harry continued to be distressed and agitated, he was given further medication to calm him. Harry remained disturbed but had periods of calm, he became fearful of isolation, he became sleepy and at around 3.30hrs on 27th December 2022, he vomited. Observations were carried out confirming that Harry had low oxygen saturations and a high temperature. At 4.45hrs his extremities were discolouring, and he became unresponsive, an ambulance was called. He was transferred back to the A&E department but died at 06.36hrs.
Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com
Dr Delaney a forensic pathologist assisted in determining the medical cause of death (noted above).
Copies Sent To
Avon & Wiltshire Mental Health NHs trust
North Bristol NHS Trust
Avon & Somerset Constabulary
Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon
coroner.com
Royal College of Psychiatrists
Inquest Conclusion
“On the basis of the evidence presented concerning the events of the morning of 26th December 2022, it is probable that the failure to act at that time contributed to the death of Harry, by delaying his transfer to a hospital environment or place of safety.
In relation to Harry's medical treatment in the Emergency Department of Southmead Hospital, prior to his transfer to the Mason Unit, the medical evidence deemed him to be medically fit for discharge, at that time. However, it is probable that the failure to take more physical observations, specifically after he had ingested more cocaine and prescribed medication, significantly contributed to the death in that the evidence for his discharge was more likely than not to have been insufficient.
Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com
Given the evidence regarding his treatment in the Mason Unit, it is probable that the failure to perform adequate observations, both physical and non-contact, contributed to Harry's death as, by failing to prioritise the accurate monitoring of his physical condition and therefore identify it's deterioration, an opportunity to transfer him promptly back into the Emergency Department was missed.”
The medical cause of death was recorded as: 1a) Sudden death, most likely as a result of terminal cardiac arrhythmia, on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology
In relation to Harry's medical treatment in the Emergency Department of Southmead Hospital, prior to his transfer to the Mason Unit, the medical evidence deemed him to be medically fit for discharge, at that time. However, it is probable that the failure to take more physical observations, specifically after he had ingested more cocaine and prescribed medication, significantly contributed to the death in that the evidence for his discharge was more likely than not to have been insufficient.
Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com
Given the evidence regarding his treatment in the Mason Unit, it is probable that the failure to perform adequate observations, both physical and non-contact, contributed to Harry's death as, by failing to prioritise the accurate monitoring of his physical condition and therefore identify it's deterioration, an opportunity to transfer him promptly back into the Emergency Department was missed.”
The medical cause of death was recorded as: 1a) Sudden death, most likely as a result of terminal cardiac arrhythmia, on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.