Alex Blake
PFD Report
All Responded
Ref: 2019-0259
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
All 2 responses received
· Deadline: 1 Nov 2019
Coroner's Concerns (AI summary)
Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
View full coroner's concerns
with respect to these individuals. The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and she assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead. Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless.
The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.
The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible.
The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court.
The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.
The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible.
The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court.
Responses
Action Taken
The NMC has referred the two registered nurses mentioned in the report to their Fitness to Practise team for further investigation, and the Employer Link Service has contacted the trust and NHS Professionals to address referral delays and ensure prompt referrals in the future. They have also referred concerns about the HCA to the Care Quality Commission. (AI summary)
The NMC has referred the two registered nurses mentioned in the report to their Fitness to Practise team for further investigation, and the Employer Link Service has contacted the trust and NHS Professionals to address referral delays and ensure prompt referrals in the future. They have also referred concerns about the HCA to the Care Quality Commission. (AI summary)
View full response
Dear Sir Re: The Late Alex James Blake Regulation 28 prevention of Future Deaths Report Further to your report to Prevent Future Deaths made under paragraph 7 , Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, am writing to provide you with the Nursing and Midwifery Council's ('NMC's') response Firstly, would like to offer my sincere condolences to Mr Blake's family for their loss, and to assure you and them that take the concerns you have raised seriously. Action we are taking in this case note that the concerns are focused on three named individuals, two of whom are registered nurses, and one of whom is healthcare assistant (HCA): have passed your report regarding the two registered nurses to our Fitness to Practise team for further investigation; we have now also received a formal referral from NHS Professionals in respect of these two nurses The case of the two nurses is now with our screening team and will use the information we have received from your office and NHS Professionals to consider the matter further. would be happy to arrange for you to receive further updates about the progress of the case if that would be helpful Our Employer Link Service (ELS) has been in touch with the trust and NHS Professionals to try to understand the delays that occurred in referring these nurses to us and to learn for the future The ELS will also be following up with the trust and NHS Professionals to ensure that there are processes in place to ensure that prompt referrals are made in appropriate cases in the future. 23 Portland Place; London W1B 1PZ T 020 7637 7181 wwwnmcorg:uk We are the professional regulatory body for nurses and midwives in the UK. Our role is to protect patients and the public through efficient and effective regulation Registered charity in England and Wales (1091434}and in Scotland (SC038362)
very they
With regard to the HCA mentioned in your letter; we are unable to direct action against this individual. Our statutory remit covers nurses, midwives and nursing associates effective on our register: However, we have referred your concerns about this individual to the Care Quality Commission, who will be able to take any action or make any recommendations consider to be appropriate in relation to the trust's use of agency staff. hope that my letter reassures you that we are taking all appropriate action to address your concerns If you have any further questions regarding this case or the action we taken , please do not hesitate to get in touch: would also like to reassure you and Mr Blake's family that it is open to them to speak to our Public Support Service for information and support concerning our fitness to practise processes will ask my colleagues in that team to contact them about the support they can provide_ Finally, please can you ensure that any future Regulation 28 prevention of Future Deaths Reports are sent to me at 23 Portland Place, London; WIB 1PZ as this will enable us to deal with any future reports as promptly as possible Thank you again for writing to me_
very they
With regard to the HCA mentioned in your letter; we are unable to direct action against this individual. Our statutory remit covers nurses, midwives and nursing associates effective on our register: However, we have referred your concerns about this individual to the Care Quality Commission, who will be able to take any action or make any recommendations consider to be appropriate in relation to the trust's use of agency staff. hope that my letter reassures you that we are taking all appropriate action to address your concerns If you have any further questions regarding this case or the action we taken , please do not hesitate to get in touch: would also like to reassure you and Mr Blake's family that it is open to them to speak to our Public Support Service for information and support concerning our fitness to practise processes will ask my colleagues in that team to contact them about the support they can provide_ Finally, please can you ensure that any future Regulation 28 prevention of Future Deaths Reports are sent to me at 23 Portland Place, London; WIB 1PZ as this will enable us to deal with any future reports as promptly as possible Thank you again for writing to me_
Action Taken
NHS Professionals has implemented measures including competency assessments for bank members, reviews with the Interim Director of Nursing, and a dedicated Clinical Governance Nurse Lead and Education Liaison Team to manage complaints and investigations. They also use a Complaints and Incidents Management System (CIMS) feedback form to address concerns raised by Client Trusts. (AI summary)
NHS Professionals has implemented measures including competency assessments for bank members, reviews with the Interim Director of Nursing, and a dedicated Clinical Governance Nurse Lead and Education Liaison Team to manage complaints and investigations. They also use a Complaints and Incidents Management System (CIMS) feedback form to address concerns raised by Client Trusts. (AI summary)
View full response
Dear Mr Harris Regulation 28 Report to Prevent Future Deaths following inquest of Alex James Blake died at Lambeth Hospital, London; on 24 June 2018 (Case Ref: 04761-2018 who am writing to you to respond to the concerns raised by surrounding the tragic death of Alex James Blake. your investigation into the circumstances de4St Professionals takes very seriously its responsibility to act upon what it learns from rdeaths of patlents, Who were cared for by Bank Members Whlist in te cara of theaNHS unexpected In your report you Identified the following Matters of Concern: The evidence of the NHS Professionals Bank Members rise mandated observations gave to concerns that the were either not performed to the requisite standard or not performed at all; and
2. Shere was Inconslstency of account given by the three Bank Members as between their statements, the records and their oral evidence, raising the possibility of distoneety t written You asked NHS Professionals to consider whether there are wider implications for the recruitment and training processes_ organisation's Your report was sent to two organisations: NHS Professionals Ltd, Suites 1A &1B, Breakspear Park; Breakspear Hemel HP2 4TZ Hempstead The Nursing & Midwifery Council; Kemble Street; London; WC2 4AN: NHS Professionals I8 wholly owned by the Department of Health and Is the leading provider of managed flexible workforce into the NHS_ NHS Professionals is not a provider of services and Bank Members to NHS organisations only: We recruit Bank Members in line with NHS provides check standards and adhere to strict Clinical Governance guidelines when employment managing Bank Members. recruiting, and NSt Professionals has been working in partnership with South London & Maudsley NHS Foundation Trust since 2008, providing general and specialist nurses and healthcare workerss Registered in Erigland & Wales no. 6704614 Registered Office: NHS Professionals Ltd, Suites IA & 1B Breakspear Park; Breakspear Way, Hetel Hletupstezd ;1P24TZ Way the three Way, training
[HS ExplanationofNHS_Professionals role_Inthe provision of flexible stefing Professionals I order to respond to the matters raised in your report; it is helpful to set out the Professionals recruits and retaing staff; and ways in which NHS work in NHS arrangements upon which those staff are a8signed to organisations: We are committed to providing safe and reliable Bank Members to Client Trusts by partnership to support the effective of patient care to the population served working in work with: by Trusts we There Is a framework for governance and assurance within NHS Professlonals Nurse who is the Director of Clinical Governance and supported by the Chief represents clinical leadership on the Board, and the Medical Director who is also the Responslble Officer: Clinical Leadership is overseen by the Clinical Governance Committee, chaired by a clinical Non-Executive Director and is a sub-committee of NHS Professionals Board: NHS Professionals works in partnership with NHS Trusts to manage temporary staffing banks on their behalf We currently manage the temporary staff banks for 10 Mentai Health Trusts and 45 Acute Trusts. We have approximately 35,000 Bank Members actively working at one time_ Staff working NHS Professionals shifts in a Cllent Trust have been recruited through one of 3 recruitment processes: Substantive Registration Substantive Registration is primary registration route , which is available to applicants who hold substantive post within a Client Trust The substantive registration process allows substantive staff;, referred to as Multi Post Holder Bank Members, to work back at the Trust where are substantively employed and in an area of work that has been authorised by a Trust Manager. All training requirements for substantive staff are delivered by the Trust; Bank Registration Recruitment Standards The Bank Registration process is available to applicants who do not hold a substantive position In an NHS Professionals Client Trust or where the applicant wants to undertake shifts at a Trust other than where they hold their substantive position: Where this is the case, an applicant will undertake one Of two routes toirecruitment: Bank Exclusive: the applicants recruited through this route are known to the Client Trust; i.e. have previously worked substantively within the Trust or have worked in the Trust through a commercial agency and are therefore known to the Trust; Following recruitment by NHS Professionals, will only work in the one Trust in which are known; Bank Only: the applicants apply to work flexibly across the NHS Professionals client base in the areas where can demonstrate: 6 months experience in the previous 2 years Successiul completion of a Knowledge Based Assessment; where applicable linked to grade and speciality. Registered in England & Wales no. 6704614 Registered Qifice: NHS Professiorials Ldl, Suites IA & 1B Breakspear Park, Breakspear Way; Hercl Hempstead HP2 4TZ the delivery the the any the they they they they
[HS Evaluating Bank Members performance Professionals NHS Professionals uses an online performance review and monitoring system concerns informally at an early stage. It identifies Bank that helps to resolve highlights any lack of skills or Members who are performing well and also client TrusanV Hss /rofexitionakrwilliedge Development Performance assessment iS completed by the will in place improvement measures for Bank Members where performance or skill deficit has been identified by a Trust poor Dohen working an assignment in a Clent Trust; NHS Professionals staff work to individual Trust Policeg and guidelines and this is managed and monitored directly by Trus? staff, as NHS Professionals; Bank Members are required, along with all Trust statisto opposed to by to date records and this is monitored and maintain accurate and up bound The Code managed directly in the Trust AIl registered nurses are by (NMC) that is the professional standards of practice and behaviour for midivives and nursing associates Under 'Practise Effectively' section 40 onthe /aodo nurses, clear and accurate records relevant to your practice'_ it states, 'Keep Action taken by Irust and NHS Professionals _following Mr Blakes death Nfs Professionals was informed of Mr Blake's death on 6 July 2018, by the Ward informed that the Bank Members were not implicated in the events Manager: were manager wanted to ensure that surrounding Mr Blake's death. The we would be able to support the Bank Members with counselling if required: The Bank Members could continue to work bank shifts within Trust. We did Sl report, not receive the The Trusthlegal team included the three Bank Members in preparation for the inquest We aware at this time that the shift on 23/24 June 2018 was staffed exclusively were not by Bank Members_ Against the above background, have set out NHS Professionals' response below to the concern you have identified and the actions which should be taken, matters of Response to Concerns: As a result of the concerns YOU have asked NHS Professionals to take the following action: FrcidS Professionals to consider whether to conduct an Internal Investigation or a fitness to practise investigation For NHS Professionals to consider the wider impllcations for NHS Professionals recruitment training and For the avoidance of doubt; it is understood that the Coroner has made a referral to the NMC In of the staff members concerned. respect Orareceipt of the Prevention of Future Deaths Report on 2 August 2019 we obtained all the information relating to the case from South London & Maudsley NHS Foundation Trustehica ecluded ehe31 report: can confirm that the concerns raised were acted upon immediately and are currently the ongoing investigations. would therefore wish to assureoall concerneel hatactton ci betlakle leerecf any identified organisational or individual deficits arising from this to remedy safety. process in the interests of patient NHS Professionals Interim Clinical Governance Director and Senior Nurse/ Head of Risk met with the Trust Interim Director of to review the process undertaken in this case. There be learned for NHS Professionals, specifically around the are lessons to communication between two organisations and about a systematic approach to information sharing: A future meeting is planned to ensureiohs Rogistered iri England & Wales rio. 6704614 Registered Office: NHS Professionals Ltd, Suites 1A & 48 Breakspear Bruakspear Wlay; Helne:l Flemipnlead 14F2 412 put We the Nursing, the Paris,
[NHSI appropriate Iinks of the lead Glinicians in both Professionals categorised and managed effectively organisations are in place s0 that cases are accurately and where action is required it is undertaken promptiy. Wider Implications NHS Professionals Recruitment and Processes Asi outlned above NHS Professionals recruits to NHS strict Clinical Governance gyidelines when employment check standards and adheres to Protessionals' roaedazoce enfidelatertorheaineguitinglic and managing Bank members NHS provision is reviewed and updated aligned to the Core Skills Framework 'Training specialist consultant aregularly &8 part %i that process we are currently and all training provision both in practice wiih and online In addition to statutory and mandatory individual Client tralning requirements for bank staff who are proyidedi Trusts may have specific additional NHS Professionals works In partnership via NHS Professionals and, where this Is the case, The Trust Wblia Cllent Trust to support delivery of this additionai iraining; Ofcofnietencegeoformanhichsecvaton Verslon 6.1 (July 2017) includes & Nursing Verification feveoof obeecationfoThis Ighirkciecgkees at corrpetericy assessment prior fo areturse" undeVakifiga This is undertaken at ward level. any Evidencing %f successful completion and update of the competency meeting with the Interim Director of Nursing andewall foerc assessment was discussed at the systems review: part of the actions to be included in the whole In addition to the above should a Client Trust have concerns about by NHS Professionals, cah inform the competence of a worker provided us about this through the Complaints and Incidente System (CIMS) feedback form' CIMS is a bespoke complaints Manaigement case management; documentation and management syster which supports Trust: NHS Professionals has on-going review of concerns that have been raised by a Client Team of 8 Registered designated Clinical Governance Nurse Lead and Education Liaison Nurses and 2 Complaints Investigators Who manage complaintu The team also manage the remediation and continuing profeosionac investigation: the outcome of investigations for Bank Members. All development (CPD) action plans at discussed monthly with Client Trusts, concerns and complaints are reviewed and monitor steps taken; who receive a full report of all ongoing cases to enable them to that te information provided offers assurances that the findings of areas of concern you have highlighted have prompted action your investigation and the commitment to providing and and have been the focus for our continuing Trusts: improving provision of safe and effective Bank Members into our Client Ifyou require further information from NHS Professionals in relation to of do not hesitate to contact me. above matter; please
2. Shere was Inconslstency of account given by the three Bank Members as between their statements, the records and their oral evidence, raising the possibility of distoneety t written You asked NHS Professionals to consider whether there are wider implications for the recruitment and training processes_ organisation's Your report was sent to two organisations: NHS Professionals Ltd, Suites 1A &1B, Breakspear Park; Breakspear Hemel HP2 4TZ Hempstead The Nursing & Midwifery Council; Kemble Street; London; WC2 4AN: NHS Professionals I8 wholly owned by the Department of Health and Is the leading provider of managed flexible workforce into the NHS_ NHS Professionals is not a provider of services and Bank Members to NHS organisations only: We recruit Bank Members in line with NHS provides check standards and adhere to strict Clinical Governance guidelines when employment managing Bank Members. recruiting, and NSt Professionals has been working in partnership with South London & Maudsley NHS Foundation Trust since 2008, providing general and specialist nurses and healthcare workerss Registered in Erigland & Wales no. 6704614 Registered Office: NHS Professionals Ltd, Suites IA & 1B Breakspear Park; Breakspear Way, Hetel Hletupstezd ;1P24TZ Way the three Way, training
[HS ExplanationofNHS_Professionals role_Inthe provision of flexible stefing Professionals I order to respond to the matters raised in your report; it is helpful to set out the Professionals recruits and retaing staff; and ways in which NHS work in NHS arrangements upon which those staff are a8signed to organisations: We are committed to providing safe and reliable Bank Members to Client Trusts by partnership to support the effective of patient care to the population served working in work with: by Trusts we There Is a framework for governance and assurance within NHS Professlonals Nurse who is the Director of Clinical Governance and supported by the Chief represents clinical leadership on the Board, and the Medical Director who is also the Responslble Officer: Clinical Leadership is overseen by the Clinical Governance Committee, chaired by a clinical Non-Executive Director and is a sub-committee of NHS Professionals Board: NHS Professionals works in partnership with NHS Trusts to manage temporary staffing banks on their behalf We currently manage the temporary staff banks for 10 Mentai Health Trusts and 45 Acute Trusts. We have approximately 35,000 Bank Members actively working at one time_ Staff working NHS Professionals shifts in a Cllent Trust have been recruited through one of 3 recruitment processes: Substantive Registration Substantive Registration is primary registration route , which is available to applicants who hold substantive post within a Client Trust The substantive registration process allows substantive staff;, referred to as Multi Post Holder Bank Members, to work back at the Trust where are substantively employed and in an area of work that has been authorised by a Trust Manager. All training requirements for substantive staff are delivered by the Trust; Bank Registration Recruitment Standards The Bank Registration process is available to applicants who do not hold a substantive position In an NHS Professionals Client Trust or where the applicant wants to undertake shifts at a Trust other than where they hold their substantive position: Where this is the case, an applicant will undertake one Of two routes toirecruitment: Bank Exclusive: the applicants recruited through this route are known to the Client Trust; i.e. have previously worked substantively within the Trust or have worked in the Trust through a commercial agency and are therefore known to the Trust; Following recruitment by NHS Professionals, will only work in the one Trust in which are known; Bank Only: the applicants apply to work flexibly across the NHS Professionals client base in the areas where can demonstrate: 6 months experience in the previous 2 years Successiul completion of a Knowledge Based Assessment; where applicable linked to grade and speciality. Registered in England & Wales no. 6704614 Registered Qifice: NHS Professiorials Ldl, Suites IA & 1B Breakspear Park, Breakspear Way; Hercl Hempstead HP2 4TZ the delivery the the any the they they they they
[HS Evaluating Bank Members performance Professionals NHS Professionals uses an online performance review and monitoring system concerns informally at an early stage. It identifies Bank that helps to resolve highlights any lack of skills or Members who are performing well and also client TrusanV Hss /rofexitionakrwilliedge Development Performance assessment iS completed by the will in place improvement measures for Bank Members where performance or skill deficit has been identified by a Trust poor Dohen working an assignment in a Clent Trust; NHS Professionals staff work to individual Trust Policeg and guidelines and this is managed and monitored directly by Trus? staff, as NHS Professionals; Bank Members are required, along with all Trust statisto opposed to by to date records and this is monitored and maintain accurate and up bound The Code managed directly in the Trust AIl registered nurses are by (NMC) that is the professional standards of practice and behaviour for midivives and nursing associates Under 'Practise Effectively' section 40 onthe /aodo nurses, clear and accurate records relevant to your practice'_ it states, 'Keep Action taken by Irust and NHS Professionals _following Mr Blakes death Nfs Professionals was informed of Mr Blake's death on 6 July 2018, by the Ward informed that the Bank Members were not implicated in the events Manager: were manager wanted to ensure that surrounding Mr Blake's death. The we would be able to support the Bank Members with counselling if required: The Bank Members could continue to work bank shifts within Trust. We did Sl report, not receive the The Trusthlegal team included the three Bank Members in preparation for the inquest We aware at this time that the shift on 23/24 June 2018 was staffed exclusively were not by Bank Members_ Against the above background, have set out NHS Professionals' response below to the concern you have identified and the actions which should be taken, matters of Response to Concerns: As a result of the concerns YOU have asked NHS Professionals to take the following action: FrcidS Professionals to consider whether to conduct an Internal Investigation or a fitness to practise investigation For NHS Professionals to consider the wider impllcations for NHS Professionals recruitment training and For the avoidance of doubt; it is understood that the Coroner has made a referral to the NMC In of the staff members concerned. respect Orareceipt of the Prevention of Future Deaths Report on 2 August 2019 we obtained all the information relating to the case from South London & Maudsley NHS Foundation Trustehica ecluded ehe31 report: can confirm that the concerns raised were acted upon immediately and are currently the ongoing investigations. would therefore wish to assureoall concerneel hatactton ci betlakle leerecf any identified organisational or individual deficits arising from this to remedy safety. process in the interests of patient NHS Professionals Interim Clinical Governance Director and Senior Nurse/ Head of Risk met with the Trust Interim Director of to review the process undertaken in this case. There be learned for NHS Professionals, specifically around the are lessons to communication between two organisations and about a systematic approach to information sharing: A future meeting is planned to ensureiohs Rogistered iri England & Wales rio. 6704614 Registered Office: NHS Professionals Ltd, Suites 1A & 48 Breakspear Bruakspear Wlay; Helne:l Flemipnlead 14F2 412 put We the Nursing, the Paris,
[NHSI appropriate Iinks of the lead Glinicians in both Professionals categorised and managed effectively organisations are in place s0 that cases are accurately and where action is required it is undertaken promptiy. Wider Implications NHS Professionals Recruitment and Processes Asi outlned above NHS Professionals recruits to NHS strict Clinical Governance gyidelines when employment check standards and adheres to Protessionals' roaedazoce enfidelatertorheaineguitinglic and managing Bank members NHS provision is reviewed and updated aligned to the Core Skills Framework 'Training specialist consultant aregularly &8 part %i that process we are currently and all training provision both in practice wiih and online In addition to statutory and mandatory individual Client tralning requirements for bank staff who are proyidedi Trusts may have specific additional NHS Professionals works In partnership via NHS Professionals and, where this Is the case, The Trust Wblia Cllent Trust to support delivery of this additionai iraining; Ofcofnietencegeoformanhichsecvaton Verslon 6.1 (July 2017) includes & Nursing Verification feveoof obeecationfoThis Ighirkciecgkees at corrpetericy assessment prior fo areturse" undeVakifiga This is undertaken at ward level. any Evidencing %f successful completion and update of the competency meeting with the Interim Director of Nursing andewall foerc assessment was discussed at the systems review: part of the actions to be included in the whole In addition to the above should a Client Trust have concerns about by NHS Professionals, cah inform the competence of a worker provided us about this through the Complaints and Incidente System (CIMS) feedback form' CIMS is a bespoke complaints Manaigement case management; documentation and management syster which supports Trust: NHS Professionals has on-going review of concerns that have been raised by a Client Team of 8 Registered designated Clinical Governance Nurse Lead and Education Liaison Nurses and 2 Complaints Investigators Who manage complaintu The team also manage the remediation and continuing profeosionac investigation: the outcome of investigations for Bank Members. All development (CPD) action plans at discussed monthly with Client Trusts, concerns and complaints are reviewed and monitor steps taken; who receive a full report of all ongoing cases to enable them to that te information provided offers assurances that the findings of areas of concern you have highlighted have prompted action your investigation and the commitment to providing and and have been the focus for our continuing Trusts: improving provision of safe and effective Bank Members into our Client Ifyou require further information from NHS Professionals in relation to of do not hesitate to contact me. above matter; please
Sent To
- NHS Professionals Ltd
- Nursing and Midwifery Council
Response Status
Linked responses
2 of 2
56-Day Deadline
1 Nov 2019
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
I opened an inquest into the death of Mr Alex Blake, who died on 24th June 2018 in Lambeth Hospital (01761-2018).
An investigation and inquest was opened on 29th June 2018 and was concluded on 27th June 2019. A jury was summoned. The medical cause of death was: 1a Heroin Toxicity
An investigation and inquest was opened on 29th June 2018 and was concluded on 27th June 2019. A jury was summoned. The medical cause of death was: 1a Heroin Toxicity
Circumstances of the Death
The jury concluded that he died from a self-administered heroin overdose whilst a sectioned in-patient under the care of South London & Maudsley Trust at Lambeth Hospital, sometime before 04.13 on 24.06.18.
The jury concluded that there were inadequate observations conducted on the night, which meant that his death went unnoticed for several hours, due to unsuitable record sheets, ineffective observations and lack of communication between staff. There was evidence that rigor mortis had begun when he was found, based on evidence of the attending paramedic.
The jury concluded that there were inadequate observations conducted on the night, which meant that his death went unnoticed for several hours, due to unsuitable record sheets, ineffective observations and lack of communication between staff. There was evidence that rigor mortis had begun when he was found, based on evidence of the attending paramedic.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths. I believe that the following organizations would wish to learn of the circumstances of this death and are in a position to mitigate or prevent future deaths: As all three are employees of NHS Professionals, the agency is informed of this evidence so that they might consider whether to conduct an internal investigation or fitness to practice investigations and additionally consider whether there are wider implications for their recruitment and training processes.
Given the serious professional and legal implications of the evidence of the nurses each is referred to the Nursing & Midwifery Council. Their identities are communicated separately and confidentially.
Given the serious professional and legal implications of the evidence of the nurses each is referred to the Nursing & Midwifery Council. Their identities are communicated separately and confidentially.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.