Stuart Clark
PFD Report
All Responded
Ref: 2019-0125A
All 1 response received
· Deadline: 9 Sep 2019
Coroner's Concerns (AI summary)
A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available in medical records.
View full coroner's concerns
(1) The evidence revealed that Mr CLARK disclosed to a member of nursing staff on Lowman (Capener) Ward at the Royal Devon and Exeter Hospital that he was a vulnerable adult and a suicide risk This disclosure was not followed up with an assessment to determine if Mr CLARK had any intent; plan or history of self-harm or suicide. An assessment would have helped determine his risk and inform the decision on a referral to mental health services.
Senior clinical staff were not directly informed of the disclosure_ The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide_ and if appropriate she would have referred him to the mental health services_ The nurse made an in the medical records; however; the medical notes were not made up until the end of the day and therefore the information was not available to other staff at the relevant time_
Senior clinical staff were not directly informed of the disclosure_ The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide_ and if appropriate she would have referred him to the mental health services_ The nurse made an in the medical records; however; the medical notes were not made up until the end of the day and therefore the information was not available to other staff at the relevant time_
Responses
Action Planned
The Trust will reinforce individual responsibility for patient safety and suicide prevention and is running a 'Care Matters' professional leadership forum in June 2019 to reiterate the importance of escalating concerns. (AI summary)
The Trust will reinforce individual responsibility for patient safety and suicide prevention and is running a 'Care Matters' professional leadership forum in June 2019 to reiterate the importance of escalating concerns. (AI summary)
View full response
Dear Mr Spinney
Re Stuart Michael Clark (Died: 03/10/2017)
I am writing further to your letter dated 5 April 2019, enclosing your Regulation 28 Report to Prevent Future Deaths.
“review procedures and training related to the actions to be taken when a disclosure is made to ward staff giving rise to the suspicion of the risk of self-harm or suicide”.
In response to this, the Royal Devon and Exeter NHS Foundation Trust (The Trust) has reviewed its current training and support available to ward staff in relation to: Recognising a person at risk (Vulnerable adult); Responding to, and escalating concerns; and Safeguarding Adults
There is a mandatory training programme that is completed by all staff on induction with the Trust, whatever their role. Regular updates are required at a maximum interval of every three years. The training programme has the following objectives: Raise awareness of safeguarding issues Be aware of signs and symptoms of abuse Understand own responsibilities to safeguard Understand Prevent issues: Recognising when vulnerable people are at risk of / have been radicalised Increase knowledge of MCA and DoLS Have knowledge of relevant procedures Know where to access support and further information.
All staff are informed at induction and in training that they are responsible for escalating concerns about safeguarding or other risks to patients. Ward staff are taught about self-neglect as part of safeguarding training. Sometimes this reaches a threshold of safeguarding referral in accordance with the Care Act. The Trust Safeguarding team is available weekdays 8.30am – 5pm to give advice to staff about any safeguarding matter. We empower staff to safeguard patients themselves, but the Safeguarding Team do also see some more complex cases themselves or with staff.
This is supported by the Trust’s Safeguarding Adults Policy, monthly Safeguarding newsletters and regularly updated information on the Trust’s intranet service “Hub”, all of these are accessible to all employees. The Hub information includes a multi-agency leaflet ‘It’s safe to talk about suicide’.
The Safer Devon Partnership, which is the statutory County Strategy Group, which provides strategic leadership for addressing community safety issues affecting vulnerable people, currently have a group reviewing suicide prevention. We will be reviewing our provision again in light of this review. Specific training has been provided from Devon Partnership Trust for our highest risk areas, AMU and Emergency Department. The Trust has mental health support available 24 hours a day from our liaison psychiatry service provided by Devon Partnership Trust.
This is what is currently in place in the Trust to ensure that staff are aware of their duties for safeguarding patients.
However, the Trust is always seeking to improve safety for its patients. We will be reinforcing individual responsibility and accountability for patient safety and suicide prevention to all staff. In June 2019, the Trust is running a two day ‘Care Matters’ professional leadership forum for Nurses, Allied Health Professionals and midwives. These sessions will be run and delivered in person by
Deputy Chief Executive/Chief Nurse, and will reach over 100 leads who will then cascade to their respective teams. The focus of this forum is Professional Safety and this case will be used during this forum as an example to reiterate the importance of escalating concerns about vulnerable patients to ensure the appropriate assessments and support can be provided to them.
The Trust is satisfied that this was an isolated incident and staff are aware of their safeguarding obligations. However, the Safeguarding Team is going to issue a reminder to all staff in an upcoming newsletter (which reaches all clinical staff) about safeguarding procedures when there is a disclosure about possible suicidal intent. This briefing will include information about the ‘It’s safe to talk about suicide’ leaflet, a copy of which is attached. This is available on the Trust’s Safeguarding intranet page but we want to raise awareness further of this issue. The leaflet was produced by Exeter Medical School in conjunction with Suicide Charities and Devon County Council for staff to use to support people when suicidal intention is disclosed.
I hope that all of the above provides reassurance that all staff are aware, and will be reminded of, their obligations of what actions to take when faced with vulnerable adults who may be at risk of self- harm. Please do not hesitate to contact me if you require any further information.
Re Stuart Michael Clark (Died: 03/10/2017)
I am writing further to your letter dated 5 April 2019, enclosing your Regulation 28 Report to Prevent Future Deaths.
“review procedures and training related to the actions to be taken when a disclosure is made to ward staff giving rise to the suspicion of the risk of self-harm or suicide”.
In response to this, the Royal Devon and Exeter NHS Foundation Trust (The Trust) has reviewed its current training and support available to ward staff in relation to: Recognising a person at risk (Vulnerable adult); Responding to, and escalating concerns; and Safeguarding Adults
There is a mandatory training programme that is completed by all staff on induction with the Trust, whatever their role. Regular updates are required at a maximum interval of every three years. The training programme has the following objectives: Raise awareness of safeguarding issues Be aware of signs and symptoms of abuse Understand own responsibilities to safeguard Understand Prevent issues: Recognising when vulnerable people are at risk of / have been radicalised Increase knowledge of MCA and DoLS Have knowledge of relevant procedures Know where to access support and further information.
All staff are informed at induction and in training that they are responsible for escalating concerns about safeguarding or other risks to patients. Ward staff are taught about self-neglect as part of safeguarding training. Sometimes this reaches a threshold of safeguarding referral in accordance with the Care Act. The Trust Safeguarding team is available weekdays 8.30am – 5pm to give advice to staff about any safeguarding matter. We empower staff to safeguard patients themselves, but the Safeguarding Team do also see some more complex cases themselves or with staff.
This is supported by the Trust’s Safeguarding Adults Policy, monthly Safeguarding newsletters and regularly updated information on the Trust’s intranet service “Hub”, all of these are accessible to all employees. The Hub information includes a multi-agency leaflet ‘It’s safe to talk about suicide’.
The Safer Devon Partnership, which is the statutory County Strategy Group, which provides strategic leadership for addressing community safety issues affecting vulnerable people, currently have a group reviewing suicide prevention. We will be reviewing our provision again in light of this review. Specific training has been provided from Devon Partnership Trust for our highest risk areas, AMU and Emergency Department. The Trust has mental health support available 24 hours a day from our liaison psychiatry service provided by Devon Partnership Trust.
This is what is currently in place in the Trust to ensure that staff are aware of their duties for safeguarding patients.
However, the Trust is always seeking to improve safety for its patients. We will be reinforcing individual responsibility and accountability for patient safety and suicide prevention to all staff. In June 2019, the Trust is running a two day ‘Care Matters’ professional leadership forum for Nurses, Allied Health Professionals and midwives. These sessions will be run and delivered in person by
Deputy Chief Executive/Chief Nurse, and will reach over 100 leads who will then cascade to their respective teams. The focus of this forum is Professional Safety and this case will be used during this forum as an example to reiterate the importance of escalating concerns about vulnerable patients to ensure the appropriate assessments and support can be provided to them.
The Trust is satisfied that this was an isolated incident and staff are aware of their safeguarding obligations. However, the Safeguarding Team is going to issue a reminder to all staff in an upcoming newsletter (which reaches all clinical staff) about safeguarding procedures when there is a disclosure about possible suicidal intent. This briefing will include information about the ‘It’s safe to talk about suicide’ leaflet, a copy of which is attached. This is available on the Trust’s Safeguarding intranet page but we want to raise awareness further of this issue. The leaflet was produced by Exeter Medical School in conjunction with Suicide Charities and Devon County Council for staff to use to support people when suicidal intention is disclosed.
I hope that all of the above provides reassurance that all staff are aware, and will be reminded of, their obligations of what actions to take when faced with vulnerable adults who may be at risk of self- harm. Please do not hesitate to contact me if you require any further information.
Sent To
- Royal Devon and Exeter NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
9 Sep 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
On 3 October 2017 an investigation was commenced into the death of Stuart Michael
Circumstances of the Death
Stuart Michael CLARK had a long history of suffering with his mental health. On 3 October 2017 he jumped into the canal at Haven Road, Exeter wearing a rucksack filled with weights: He was recovered from the water and taken to the Royal Devon and Exeter Hospital where he sadly died shortly after arriving: More specifically, Mr CLARK had a history of Asperger's Syndrome, Dyspraxia, Developmental Dyslexia and Irlen's Syndrome_ In the weeks before he died he complained of a rash, pain and swelling believed to be an allergic reaction; On 30 September 2017 he was admitted to the Royal Devon and Exeter Hospital due to pain, swelling and a history of diarrhoea and nausea; on assessment he was extremely anxious and concerned about his physical illness_ During his admission he disclosed to a nurse on the ward that he was a vulnerable adult and a suicide risk: This information was not escalated, and no assessment was made to determine his risk of self-harm and suicide
Action Should Be Taken
(1) Consideration should be given to reviewing procedures and training related to the actions to be taken when a disclosure is made to ward staff giving rise to a suspicion of the risk of self-harm or suicide. In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.