Ellie Long
PFD Report
All Responded
Ref: 2019-0090A
All 1 response received
· Deadline: 9 Aug 2019
Coroner's Concerns (AI summary)
The coroner highlights failures in record keeping and communication with external agencies, specifically that records were not properly recorded, handwritten notes were not reflected in electronic records and updating information was not sent to the GP or school.
View full coroner's concerns
Record keeping Auditing of Record keeping Long and and
Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing: It is, of course; imperative that all staff recognise their obligations in respect of keeping full contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids potential delay in the inquest process and further distress to the family b) Some action has been taken by NSFT in this respect; not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping: An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved: Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual'$ mind, especially when under time pressure: Good record keeping is an integral part of good service and must be second nature to all staff. It must be fully appreciated by all as "a vital component in the management of risk" . Further, record keeping has been raised elsewhere as a matter of concern within NSFT. d) have concern that full record keeping and disclosure requirements will not remain a priority. Communication with External Agencies An initial full; updating letter was sent to Ellie's GP. However no further updating information was sent: A letter was written providing updating information, but this was not sent: No further updating information was sent to the GP by telephone; letter or email: b) The evidence heard is that efforts were made to contact the school by telephone: However, the school had no record of any such calls. There is no evidence of email or written correspondence or further telephone calls in an effort to communicate with the school: It is accepted by the Trust that sharing of relevant information is necessary. NSFT has indicated it will "remind staff of the importance of recording efforts to share information/maintain communication: Sharing of information and communication with external agencies is a matter which has been raised with NSFT on previous occasions The importance of "recording efforts to share information may not be sufficient to prevent future deaths. It is the importance of shaIg information and communicating with external agencies that should be addressed here: Recording of information is dealt with at Point 1 above:
Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing: It is, of course; imperative that all staff recognise their obligations in respect of keeping full contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids potential delay in the inquest process and further distress to the family b) Some action has been taken by NSFT in this respect; not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping: An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved: Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual'$ mind, especially when under time pressure: Good record keeping is an integral part of good service and must be second nature to all staff. It must be fully appreciated by all as "a vital component in the management of risk" . Further, record keeping has been raised elsewhere as a matter of concern within NSFT. d) have concern that full record keeping and disclosure requirements will not remain a priority. Communication with External Agencies An initial full; updating letter was sent to Ellie's GP. However no further updating information was sent: A letter was written providing updating information, but this was not sent: No further updating information was sent to the GP by telephone; letter or email: b) The evidence heard is that efforts were made to contact the school by telephone: However, the school had no record of any such calls. There is no evidence of email or written correspondence or further telephone calls in an effort to communicate with the school: It is accepted by the Trust that sharing of relevant information is necessary. NSFT has indicated it will "remind staff of the importance of recording efforts to share information/maintain communication: Sharing of information and communication with external agencies is a matter which has been raised with NSFT on previous occasions The importance of "recording efforts to share information may not be sufficient to prevent future deaths. It is the importance of shaIg information and communicating with external agencies that should be addressed here: Recording of information is dealt with at Point 1 above:
Responses
Action Planned
Norfolk and Suffolk NHS Trust details actions planned including; instructing all clinical services to review their working practice in respect of record keeping and communication with partner agencies and a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager. (AI summary)
Norfolk and Suffolk NHS Trust details actions planned including; instructing all clinical services to review their working practice in respect of record keeping and communication with partner agencies and a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager. (AI summary)
View full response
Dear Lake Re: Ms Ellie Long write in response to your prevention of future deaths report dated 18 March 2019 following the conclusion of the inquest into the death of Ms Ellie Long: know you will share a copy of this response with Ellie's family and would like to express my condolences for their loss. Ellie's death is a tragedy and it is essential the Trust takes all opportunity to learn. The report raised concern in two areas_ Record keeping The report detailed that not all records were entered on to the Trust's electronic health record system: Further; some meeting notes recorded by hand were not subsequently reflected within the record. The inquest heard evidence of the actions the team have taken to improve this area, audit as a means to provide confirmation and assurance_ Communication with external agencies The report noted the importance of recording the attempts at contact with partner agencies, but highlighted it is the actual contact being made that is the critical action It is positive to note that the team have taken action in response to this learning: However; it is foreseeable that the aspect of record keeping and communication could be present in any team. The Trust is taking the following actions which are anticipated to assist in bringing consistent and sustained improvement: All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to drive improvement: Supporting this is a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager. The session will have a specific focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication. The Trust is strengthening its clinical and service leadership to ensure they have the necessary breadth of skills and resource to lead safe and effective services. Of particular note, the Trust will be introducing Patient Participation Leads for each locality, who will work alongside new Clinical Directors to lead the components of quality and patient experience_ The Trust is finalising the recruitment to these roles which will be effective from September 2019. function of this new approach will be the Working Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 SBE for better mental health Tel: 01603 421421 Fax: 01603 421341 wnsft nhs uk MAY_ 2019 King May ` Mrs using fully key
accountability to share learning, implement and monitor recommendations from serious incidents. Their role is to support the local clinical services function effectively, working alongside their network of partner agencies_ The Trust will gain assurance these interventions are working through a number of indicators. This will include audit; user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement Thank you for providing this report to the Trust. These are important matters which require diligent attention at all levels of the Trust in order to provide safe and effective care_
accountability to share learning, implement and monitor recommendations from serious incidents. Their role is to support the local clinical services function effectively, working alongside their network of partner agencies_ The Trust will gain assurance these interventions are working through a number of indicators. This will include audit; user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement Thank you for providing this report to the Trust. These are important matters which require diligent attention at all levels of the Trust in order to provide safe and effective care_
Sent To
- Norfolk & Suffolk NHS Trust
Response Status
Linked responses
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56-Day Deadline
9 Aug 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 13/12/2017 commenced an investigation into the death of Ellie Jane LONG, aged 15. The investigation concluded at the end of the inquest on 16/01/2019 The conclusion of the inquest was: Ellie took action to end her own life: The evidence does not reveal whether she intended to die. The medical cause of death was: 1a Hypoxic Brain Injury 1b Cardiac Arrest 1c Hanging Anorexia, Depression
Circumstances of the Death
Ellie Long was receiving treatment in the community from the Eating Disorder Service. She was diagnosed with Anorexia Nervosa and Depression: On the morning of 10 December 2017, Miss Long went to her bedroom, where she was found hanging later that morning: Emergency Services were called, Miss Long was taken to Norfolk and Norwich University Hospital where she died on 12 December 2017.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.