David Walker
PFD Report
All Responded
Ref: 2021-0357
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
All 1 response received
· Deadline: 15 Dec 2021
Coroner's Concerns (AI summary)
Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of the patient's risks.
View full coroner's concerns
1. Between end of May 2020 to November 2020, Mr Walker was allocated four different care co-ordinators. There was evidence that only one of these care co ordinators established a therapeutic relationship with Mr Walker. Many of the care co-ordinators were locum staff.
2. On admission to hospital on the 10th November 2020 no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker. Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information that should have been available to the North East London Foundation Trust team. There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought.
2. On admission to hospital on the 10th November 2020 no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker. Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information that should have been available to the North East London Foundation Trust team. There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought.
Responses
Action Taken
The Trust has hired agency staff on a semi-permanent basis, approved budget for reduced caseloads, provided training and supervision for staff, and amended the electronic admission checklist to include prompts for obtaining collateral information from other Trusts. (AI summary)
The Trust has hired agency staff on a semi-permanent basis, approved budget for reduced caseloads, provided training and supervision for staff, and amended the electronic admission checklist to include prompts for obtaining collateral information from other Trusts. (AI summary)
View full response
Dear Miss Persaud
Re: Inquest Touching upon the death of David Ayotunde Walker
I refer to your letter dated 21st October 2021 and the enclosed Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.
Concerns At the conclusion of the hearing into the death of David Ayotunde Walker, you expressed concern on the matters below as follows:
1. Between end of May 2020 to November 2020, Mr Walker was allocated four different care coordinators. There was evidence that only one of these care coordinators established a therapeutic relationship with Mr Walker. Many of the care coordinators were locum staff.
2. On admission to hospital on the 10th November 2020, no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker. Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information, that should have been available to the North East London Foundation Trust team. There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought.
We have taken the following actions in relation to your concerns:
High turnover of care coordinators and only one formed a therapeutic relationship To act on the concerns immediately, agency staff have been sourced to support the Waltham Forest Community Recovery Teams. These staff have been recruited on a semi-permanent basis, whilst staff recruitment is taking place.
PRIVATE AND CONFIDENTIAL
Miss N Persaud Her Majesty’s Coroner East London Walthamstow Coroners Court
Chair: Chief Executive:
Approval has been given for the service to recruit over the establishment budget to allow for reduced caseloads, so care coordinators can build relationships with patients.
All staff, including temporary staff will be supported with training during induction and will be provided clinical supervision, to ensure that they are appropriately managing patients’ identified risks and are building relationship with patients they work with.
All clinical supervisors will be provided with a template / prompt that highlights the key elements of care coordination such as relationship building, risk management and caseload management, so staff are supported in their work with patients.
The service has explored new ways of delivering care to ensure all patients on the caseload are appropriately managed. The new proposal will introduce a high intensity and lower intensity caseload management model, which will include risk management at every level with senior staff supervision.
No evidence collateral healthcare information sought Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.
I would like to take this opportunity to thank you for raising your concerns as part of the inquest. We find the learning from inquests extremely valuable and are very grateful for your comprehensive investigations, which benefit not only the families of the deceased, but also the Trust and its current & future service users.
Re: Inquest Touching upon the death of David Ayotunde Walker
I refer to your letter dated 21st October 2021 and the enclosed Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.
Concerns At the conclusion of the hearing into the death of David Ayotunde Walker, you expressed concern on the matters below as follows:
1. Between end of May 2020 to November 2020, Mr Walker was allocated four different care coordinators. There was evidence that only one of these care coordinators established a therapeutic relationship with Mr Walker. Many of the care coordinators were locum staff.
2. On admission to hospital on the 10th November 2020, no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker. Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information, that should have been available to the North East London Foundation Trust team. There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought.
We have taken the following actions in relation to your concerns:
High turnover of care coordinators and only one formed a therapeutic relationship To act on the concerns immediately, agency staff have been sourced to support the Waltham Forest Community Recovery Teams. These staff have been recruited on a semi-permanent basis, whilst staff recruitment is taking place.
PRIVATE AND CONFIDENTIAL
Miss N Persaud Her Majesty’s Coroner East London Walthamstow Coroners Court
Chair: Chief Executive:
Approval has been given for the service to recruit over the establishment budget to allow for reduced caseloads, so care coordinators can build relationships with patients.
All staff, including temporary staff will be supported with training during induction and will be provided clinical supervision, to ensure that they are appropriately managing patients’ identified risks and are building relationship with patients they work with.
All clinical supervisors will be provided with a template / prompt that highlights the key elements of care coordination such as relationship building, risk management and caseload management, so staff are supported in their work with patients.
The service has explored new ways of delivering care to ensure all patients on the caseload are appropriately managed. The new proposal will introduce a high intensity and lower intensity caseload management model, which will include risk management at every level with senior staff supervision.
No evidence collateral healthcare information sought Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.
I would like to take this opportunity to thank you for raising your concerns as part of the inquest. We find the learning from inquests extremely valuable and are very grateful for your comprehensive investigations, which benefit not only the families of the deceased, but also the Trust and its current & future service users.
Sent To
- North East London Foundation Trust
Response Status
Linked responses
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56-Day Deadline
15 Dec 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
Report Sections
Investigation and Inquest
On the 23rd December 2020 I commenced an investigation into the death of David Ayontunde Walker aged 27 years. The investigation concluded at the end of the inquest on 20th October 2021. The conclusion of the inquest was a narrative conclusion: Mr Walker took his own life on the 27th November 2020. This was, in part, because risk information was not correctly shared between two treating mental health trusts; the risk of David taking his own life was not fully assessed and necessary precautions were not taken on his discharge from hospital on 23rd November 2020.
Circumstances of the Death
David Walker suffered from mental and behavioural disorder due to drug use. His mental health deteriorated from January 2020. In July 2020, David attended London Bridge with the intention of . He was too scared and did not take any action at that time. Two days later he attended
. A member of the public called the emergency services and David was admitted to the Newham Centre for Mental Health (under East London Foundation Trust). David remained an in-patient until 11 August 2020. Very shortly after his discharge from hospital, David attended a
. He was taken back to the Newham Centre for Mental Health where he was admitted for a further short period. During July and August 2020, David was also under the care of the community recovery team of North East London Foundation Trust. He had a care co-ordinator allocated to him by North East London Foundation Trust. This information about the care co-ordinator was available to East London Foundation Trust, but there was no contact with the North East London Foundation Trust care co-ordinator. The North East London Foundation Trust care co-ordinator did not elicit the risk information from David and did not make enquiries of East London Foundation Trust. On the 9 November 2020, David travelled to
. He was admitted to a local hospital under section 2 of the Mental Health Act, and was transferred under section to Goodmayes Hospital (North East London Foundation Trust). David's mental health improved during the course of the admission. The in-patient team did not seek collateral information from East London Foundation Trust and were unaware of the incidents in July and August 2020. The discharge risk assessment was therefore, incomplete. Had the Consultant been aware of the prior incidents, she would have considered a longer inpatient admission; considered granting leave under the supervision of the home treatment team or discharge under the care of the home treatment team. Instead, David was discharged to the community recovery team. There was one telephone discussion with David on the 25 November 2020, by the team at Goodmayes Hospital. On the 27 November 2020, David's mental health appeared to deteriorate after a return to work interview. David was found during the evening of 27 November 2020. His life was pronounced extinct on scene. Police attended and deemed the circumstances as non-suspicious.
. A member of the public called the emergency services and David was admitted to the Newham Centre for Mental Health (under East London Foundation Trust). David remained an in-patient until 11 August 2020. Very shortly after his discharge from hospital, David attended a
. He was taken back to the Newham Centre for Mental Health where he was admitted for a further short period. During July and August 2020, David was also under the care of the community recovery team of North East London Foundation Trust. He had a care co-ordinator allocated to him by North East London Foundation Trust. This information about the care co-ordinator was available to East London Foundation Trust, but there was no contact with the North East London Foundation Trust care co-ordinator. The North East London Foundation Trust care co-ordinator did not elicit the risk information from David and did not make enquiries of East London Foundation Trust. On the 9 November 2020, David travelled to
. He was admitted to a local hospital under section 2 of the Mental Health Act, and was transferred under section to Goodmayes Hospital (North East London Foundation Trust). David's mental health improved during the course of the admission. The in-patient team did not seek collateral information from East London Foundation Trust and were unaware of the incidents in July and August 2020. The discharge risk assessment was therefore, incomplete. Had the Consultant been aware of the prior incidents, she would have considered a longer inpatient admission; considered granting leave under the supervision of the home treatment team or discharge under the care of the home treatment team. Instead, David was discharged to the community recovery team. There was one telephone discussion with David on the 25 November 2020, by the team at Goodmayes Hospital. On the 27 November 2020, David's mental health appeared to deteriorate after a return to work interview. David was found during the evening of 27 November 2020. His life was pronounced extinct on scene. Police attended and deemed the circumstances as non-suspicious.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.