David Ball
PFD Report
All Responded
Ref: 2020-0251
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
All 2 responses received
· Deadline: 12 Jan 2021
Coroner's Concerns (AI summary)
Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.
View full coroner's concerns
Evidence emerged during the inquest of two areas of concern: Different health care departments have different patient care records and the departments did not communicate with one another. Evidence was heard that healthcare professionals would have to rely on professional curiosity to ascertain crucial information regarding their patients. The examples used within the Inquest of David Ball were that the Hospital, Social Care and Derbyshire Healthcare all had different patient care records.
Responses
Action Planned
NHS England has reviewed Mr Ball’s care and identified actions, including; sharing lessons from deaths through a Midlands Learning from Deaths Forum, which will consider system improvements complimentary to the move to a Shared Care Record, which is not likely to be completed until 2024. (AI summary)
NHS England has reviewed Mr Ball’s care and identified actions, including; sharing lessons from deaths through a Midlands Learning from Deaths Forum, which will consider system improvements complimentary to the move to a Shared Care Record, which is not likely to be completed until 2024. (AI summary)
View full response
Dear Ms Serrano,
Re: Regulation 28 Report to Prevent Future Deaths – David Ball
Thank you for your Regulation 28 Report (from hereon, ‘report’) dated 24 November 2020 concerning the death of David Ball on 1 June 2018. Firstly, I would like to express my deep condolences to Mr Ball’s family. Secondly, I am sorry that it has taken so long to respond to this report.
The regulation 28 report concludes Mr Ball’s death was a result of Methadone and Venlafaxine misuse.
Following the inquest you raised concerns in your report to NHS England and NHS Improvement (NHS E/I) that his death was contributed to by a discharge care plan, put in place on his discharge from an informal inpatient stay in the Hartington Unit on the 1st June 2018. Your concerns suggest that the discharge plan was not fully implemented by the community mental health teams. You further highlighted concerns that different healthcare departments have different patient care records and that departments did not communicate with one another. You pointed out that professionals would have to rely on ‘professional curiosity’ in order to ascertain crucial information regarding their patients. Furthermore, the providers involved in the final days and weeks of this Mr Ball’s journey all had different care records which contributed to the communication challenges.
We are deeply saddened by the tragic death of Mr Ball and have taken this matter extremely seriously, having reviewed separate Serious Incident reports and statements from all the providers involved in Mr Ball’s care.
In addressing your concerns and considering any risks going forward my colleagues in the Midlands Region have undertaken a review of Mr Ball’s care and identified actions as follows:
Ms Emma Serrano Assistant Coroner, Derby and Derbyshire Area St Katherine's House St Mary's Wharf Mansfield Road Derby DE1 3TQ
Professor
National Medical Director Skipton House 80 London Road SE1 6LH
18th June 2021
NHS England and NHS Improvement
- Shared Care Record: a clear plan is in place to bring together a shared care record for Derby and Derbyshire that plans to address the problems where there are multiple healthcare providers involved in a person’s care. This work is unlikely to be completed until 2024. In the meantime, there are systems in place to facilitate shared care conversations which include a Mental Health Liaison Team who will share relevant details on request and where appropriate in line with data protection regulations and a Mental Health Risk Triage Assessment Form, in use at Chesterfield Royal Hospital (CRH). This triage assessment form is designed to prompt the professional completing it to contact the Mental Health Liaison Team where a risk is identified. In Mr Ball’s case, it is accepted that this system was impacted by him not providing any history of mental health concerns to the staff at CRH and denying being on any medication;
- Learning from Deaths: in the Midlands a Learning from Deaths Forum has been established which brings together Acute, Community and Mental Health Trusts as well as the Regional Medical Examiner. A suitably anonymised case study of Mr Ball’s experience has been taken to this forum for consideration, shared awareness and learning. It is accepted that “professional curiosity” or clinical judgement plays a major part in determining health risks and it is unlikely that a system can replace such decision-making which is supported by the significant training medical and nursing staff undertake to carry out their roles. The Forum will be tasked with considering system improvements complimentary to the move to a Shared Care Record and any recommendations will be escalated nationally through NHS E/I’s Executive Quality Group and associated sub-group which considers learning and improvement from these matters.
Thank you for bringing this important patient safety issue to our attention and please do not hesitate to contact us if you require any further information.
Re: Regulation 28 Report to Prevent Future Deaths – David Ball
Thank you for your Regulation 28 Report (from hereon, ‘report’) dated 24 November 2020 concerning the death of David Ball on 1 June 2018. Firstly, I would like to express my deep condolences to Mr Ball’s family. Secondly, I am sorry that it has taken so long to respond to this report.
The regulation 28 report concludes Mr Ball’s death was a result of Methadone and Venlafaxine misuse.
Following the inquest you raised concerns in your report to NHS England and NHS Improvement (NHS E/I) that his death was contributed to by a discharge care plan, put in place on his discharge from an informal inpatient stay in the Hartington Unit on the 1st June 2018. Your concerns suggest that the discharge plan was not fully implemented by the community mental health teams. You further highlighted concerns that different healthcare departments have different patient care records and that departments did not communicate with one another. You pointed out that professionals would have to rely on ‘professional curiosity’ in order to ascertain crucial information regarding their patients. Furthermore, the providers involved in the final days and weeks of this Mr Ball’s journey all had different care records which contributed to the communication challenges.
We are deeply saddened by the tragic death of Mr Ball and have taken this matter extremely seriously, having reviewed separate Serious Incident reports and statements from all the providers involved in Mr Ball’s care.
In addressing your concerns and considering any risks going forward my colleagues in the Midlands Region have undertaken a review of Mr Ball’s care and identified actions as follows:
Ms Emma Serrano Assistant Coroner, Derby and Derbyshire Area St Katherine's House St Mary's Wharf Mansfield Road Derby DE1 3TQ
Professor
National Medical Director Skipton House 80 London Road SE1 6LH
18th June 2021
NHS England and NHS Improvement
- Shared Care Record: a clear plan is in place to bring together a shared care record for Derby and Derbyshire that plans to address the problems where there are multiple healthcare providers involved in a person’s care. This work is unlikely to be completed until 2024. In the meantime, there are systems in place to facilitate shared care conversations which include a Mental Health Liaison Team who will share relevant details on request and where appropriate in line with data protection regulations and a Mental Health Risk Triage Assessment Form, in use at Chesterfield Royal Hospital (CRH). This triage assessment form is designed to prompt the professional completing it to contact the Mental Health Liaison Team where a risk is identified. In Mr Ball’s case, it is accepted that this system was impacted by him not providing any history of mental health concerns to the staff at CRH and denying being on any medication;
- Learning from Deaths: in the Midlands a Learning from Deaths Forum has been established which brings together Acute, Community and Mental Health Trusts as well as the Regional Medical Examiner. A suitably anonymised case study of Mr Ball’s experience has been taken to this forum for consideration, shared awareness and learning. It is accepted that “professional curiosity” or clinical judgement plays a major part in determining health risks and it is unlikely that a system can replace such decision-making which is supported by the significant training medical and nursing staff undertake to carry out their roles. The Forum will be tasked with considering system improvements complimentary to the move to a Shared Care Record and any recommendations will be escalated nationally through NHS E/I’s Executive Quality Group and associated sub-group which considers learning and improvement from these matters.
Thank you for bringing this important patient safety issue to our attention and please do not hesitate to contact us if you require any further information.
Noted
NHS Digital explains their role in providing the Summary Care Record (SCR), confirms that Mr. Ball's record was checked and no anomalies were found, and notes that the discharge care plan is not the kind of information held within the SCR. They also note that there are initiatives to introduce systems that enable patient records to be shared and accessible between all health and care providers in a locality. (AI summary)
NHS Digital explains their role in providing the Summary Care Record (SCR), confirms that Mr. Ball's record was checked and no anomalies were found, and notes that the discharge care plan is not the kind of information held within the SCR. They also note that there are initiatives to introduce systems that enable patient records to be shared and accessible between all health and care providers in a locality. (AI summary)
View full response
Dear Miss Serrano, Inquest into the death of Mr David Ball am writing in response to the Regulation 28 report received from HM Coroner dated 25 November 2020. This follows the investigation and inquest into the death of Mr David Ball; who sadly died on 30 June 2019.| would like to express my sincerest condolences to Mr Ball's family_ We would also like to apologise for the lateness for the return of this letter due to administrative issues_ NHS Digital is a non-departmental public body created by the Health and Social Care Act 2012 and is the national information and technology partner for the health and care system: We use technology to support the NHS and social care have asked in paragraph 5, if NHS Digital has any information that can explain why "different health care departments have different patient records and the departments did not communicate with one another: Organisations have arrangements and systems in place to keep and maintain patient records whether electronic or not; and organisations share these records in accordance with their processes and procedures_ NHS Digital is not responsible for all the systems that hold patient information: We do provide and have responsibility for the Summary Care Record (SCR') The SCR helps professionals across care settings to access GP held information on GP prescribed medications , patient allergies and adverse reactions (SCR core functionality) , and clinicians in urgent and emergency care settings access key GP-held information for patients previously identified by GPs as most to present in urgent and emergency care) (SCR with Additional Information). Information and technology WWW . 'digital nhs.uk for better health and care enquiries@nhsdigital.nhs.uk You likely
NHS] Digital The patient record of Mr Ball has been checked within the SCR system by the Personal Demographic Service team at NHS Digital. It is confirmed that there was no duplicate record for Mr Ball, and no anomalies were identified . The SCR is populated by GPs in their respective medical practices_ The SCR holds the following GP information about the patient: the name, address, date of birth and NHS Number; current medication; allergies and details of any previous bad reactions to medicines; details of long-term conditions; any significant medical history; and specific communication needs_ However , whilst notes and significant medical history may be included by the GP, the Discharge Care Plan is not the kind of information that is held and shared within the summary record. We understand from the request that the discharge care plan was not followed; and this was not recognised. This is an issue of health and social care coordination and management: In this context; and also outside NHS Digital's area of responsibility, it is worth noting that there are numerous initiatives across the NHS and social care to introduce systems that enable patient records to be shared and accessible between all health and care providers in a locality. Such systems would be expected to improve the planning and provision of shared care, and reduce the risk of miscommunication. These initiatives are at different levels of maturity, but can be expected to become increasingly widely-used. If HM Coroner requires any further clarification in relation to any point; please do not hesitate to contact us and we can assist further.
NHS] Digital The patient record of Mr Ball has been checked within the SCR system by the Personal Demographic Service team at NHS Digital. It is confirmed that there was no duplicate record for Mr Ball, and no anomalies were identified . The SCR is populated by GPs in their respective medical practices_ The SCR holds the following GP information about the patient: the name, address, date of birth and NHS Number; current medication; allergies and details of any previous bad reactions to medicines; details of long-term conditions; any significant medical history; and specific communication needs_ However , whilst notes and significant medical history may be included by the GP, the Discharge Care Plan is not the kind of information that is held and shared within the summary record. We understand from the request that the discharge care plan was not followed; and this was not recognised. This is an issue of health and social care coordination and management: In this context; and also outside NHS Digital's area of responsibility, it is worth noting that there are numerous initiatives across the NHS and social care to introduce systems that enable patient records to be shared and accessible between all health and care providers in a locality. Such systems would be expected to improve the planning and provision of shared care, and reduce the risk of miscommunication. These initiatives are at different levels of maturity, but can be expected to become increasingly widely-used. If HM Coroner requires any further clarification in relation to any point; please do not hesitate to contact us and we can assist further.
Sent To
- NHS Digital
- NHS England
Response Status
Linked responses
2 of 2
56-Day Deadline
12 Jan 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 3 July 2018 I commenced an investigation into the death of David BALL. The investigation concluded at the end of the inquest 18th April 2018. The conclusion of the inquest was a suicide conclusion as follows: "Suicide contributed to by a discharge care plan, put in place on his discharge from an informal inpatient stay on the Hartington Unit on the 1 June 2018, not being fully implemented by the community mental health teams" The medical cause of death was la) Methadone and Venlafaxine misuse
Circumstances of the Death
1. Between the 12 March 2019 and the 1 June 2019 David Ball was a voluntary patient at the Hartington Unit, which is a mental health unit. This was due to an extensive mental health history including suicide by overdose attempts. David Ball had a history of depression, paranoia, delusions and hallucinations. In addition, he had a history of drugs misuse. He had a past history of deliberate overdose attempts when distressed and suffering from delusions.
2. On the 1 June 2019 he was deemed fit for discharge. His discharge care plan dictated that he was allocated a Community Psychiatric Nurse, he was visited by a Social Worker 3 times per day and he wold be supported by the Community.
3. He did not receive a Community Psychiatric Nurse, he received 3 social worker visits per day until the 4 June, and he has support bf the Community Mental Health Team. He was admitted to Chesterfield Royal Hospital from the 4 June 2019 to the 17 June 2019. This was for unrelated matters. From the 4 June, to the date of his passing on the 30 June 2019 his discharge care plan was not carried out.
4. The issues identified at inquest were firstly, the assumption that a Community Psychiatric Nurse would be allocated to David Ball. This was incorrect and would be subject to a decision making 8 process. The outcome of which was that he was not allocated one. Secondly, there was assumed communication with the sending of an email, with no process for ascertaining that it was received or actioned. Finally, different health care departments have different patient care records and the departments did not communicate with one another. Evidence was heard that healthcare professionals would have to rely on professional .curiosity to ascertain crucial information regarding their patients.
5. It was accepted that David Ball did not get the help and support envisaged when the Discharge Care Plan from the Hartington Unit was drafted.
6. On the 30 June 2019 David Ball was found deceased at his home address having taken amounts of methadone and venlafaxine not compatible with life. He did so with the intention of taking his own life after delusions and paranoia presented. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Evidence emerged during the inquest of two areas of concern: Different health care departments have different patient care records and the departments did not communicate with one another. Evidence was heard that healthcare professionals would have to rely on professional curiosity to ascertain crucial information regarding their patients. The examples used within the Inquest of David Ball were that the Hospital, Social Care and Derbyshire Healthcare all had different patient care records. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 January 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1. The Family of Mr David Ball;
2. NHS England; and
3. NHS Digital. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 24 November 2020 Signature~'~,U Emma Serrano Assistant Coroner Derby and Derby~hire Coroners Area 9
2. On the 1 June 2019 he was deemed fit for discharge. His discharge care plan dictated that he was allocated a Community Psychiatric Nurse, he was visited by a Social Worker 3 times per day and he wold be supported by the Community.
3. He did not receive a Community Psychiatric Nurse, he received 3 social worker visits per day until the 4 June, and he has support bf the Community Mental Health Team. He was admitted to Chesterfield Royal Hospital from the 4 June 2019 to the 17 June 2019. This was for unrelated matters. From the 4 June, to the date of his passing on the 30 June 2019 his discharge care plan was not carried out.
4. The issues identified at inquest were firstly, the assumption that a Community Psychiatric Nurse would be allocated to David Ball. This was incorrect and would be subject to a decision making 8 process. The outcome of which was that he was not allocated one. Secondly, there was assumed communication with the sending of an email, with no process for ascertaining that it was received or actioned. Finally, different health care departments have different patient care records and the departments did not communicate with one another. Evidence was heard that healthcare professionals would have to rely on professional .curiosity to ascertain crucial information regarding their patients.
5. It was accepted that David Ball did not get the help and support envisaged when the Discharge Care Plan from the Hartington Unit was drafted.
6. On the 30 June 2019 David Ball was found deceased at his home address having taken amounts of methadone and venlafaxine not compatible with life. He did so with the intention of taking his own life after delusions and paranoia presented. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Evidence emerged during the inquest of two areas of concern: Different health care departments have different patient care records and the departments did not communicate with one another. Evidence was heard that healthcare professionals would have to rely on professional curiosity to ascertain crucial information regarding their patients. The examples used within the Inquest of David Ball were that the Hospital, Social Care and Derbyshire Healthcare all had different patient care records. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 January 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1. The Family of Mr David Ball;
2. NHS England; and
3. NHS Digital. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 24 November 2020 Signature~'~,U Emma Serrano Assistant Coroner Derby and Derby~hire Coroners Area 9
Copies Sent To
2. NHS England; and
Inquest Conclusion
"Suicide contributed to by a discharge care plan, put in place on his discharge from an informal inpatient stay on the Hartington Unit on the 1 June 2018, not being fully implemented by the community mental health teams" The medical cause of death was la) Methadone and Venlafaxine misuse
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.