John Richardson
PFD Report
All Responded
Ref: 2019-0084
All 1 response received
· Deadline: 3 May 2019
Coroner's Concerns (AI summary)
Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental Health Act.
View full coroner's concerns
(1) The Jury in their Narrative Conclusion confirmed that they agreed with the findings in the Serious Incident Report compiled by and the 9 key failings by the Trust. However I am satisfied that since John Richardson’s death measures appear to have been put in place to address all these issues.
(2) However the death of Mr Richardson appears to have occurred when there was some confusion amongst staff with regards to Mr Richardson’s leave status. This was identified by the Jury in their conclusion. Whilst some guidance is provided to staff, with regards to voluntary patients taking leave, there is no specific Leave Policy for Voluntary Patients in the same way as there is one for those patients sectioned under the Mental Health Act.
(2) However the death of Mr Richardson appears to have occurred when there was some confusion amongst staff with regards to Mr Richardson’s leave status. This was identified by the Jury in their conclusion. Whilst some guidance is provided to staff, with regards to voluntary patients taking leave, there is no specific Leave Policy for Voluntary Patients in the same way as there is one for those patients sectioned under the Mental Health Act.
Responses
Action Taken
Guidance regarding voluntary patients leaving the wards has been included in the new Acute Care Operational Policy. (AI summary)
Guidance regarding voluntary patients leaving the wards has been included in the new Acute Care Operational Policy. (AI summary)
View full response
Dear Ms Schofield Re: Inquest into the death of John Peter Richardson Thank you for your letter dated 8 March 2019 enclosing your Report to Prevent Future Deaths under Regulation 28 Coroners (Investigations) Regulations
2013. write to formally respond and to provide you with details of the action taken by the Trust as a result of the concern that you have raised. Following Mr Richardson's tragic death, the Serious Incident Investigator, Lorrainne Biddle, met with me to go through all the failings she identified. She did this because of the level of her concern, because she knew that would want oversight and so that | could contact the family at the earliest opportunity. was pleased to hear that the agreed with her findings and that you were satisfied with the measures that we in place to address matters. This was a particularly sad case and have, since the Inquest, met with Mr Richardson's wife and one of his daughters to offer personal apology and provide ongoing assurance as to the actions that have been taken_ Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff's understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy: have enclosed copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients_ Presenting the guidance in this way was considered to be preferable to any further stand alone policy. It is hoped that this will be highly accessible and provide immediate access to the principles, coupled with signposting to other documents if more information is required. Chair: Peter Molyneux Chief Executive: Samantha Allen Head office: Sussex Partnership NHS Foundation Trust, Swandean;, Arundel Road, Worthing, West Sussex, BN13 3EP M sussexpartnership nhs uk teaching trust of Brighton and Sussex Medical School May Jury put key
hope that the content of the enclosed addresses your concern and provides you with complete reassurance. However; if any further clarification is required or can assist further in any way then please do not hesitate to contact me_
2013. write to formally respond and to provide you with details of the action taken by the Trust as a result of the concern that you have raised. Following Mr Richardson's tragic death, the Serious Incident Investigator, Lorrainne Biddle, met with me to go through all the failings she identified. She did this because of the level of her concern, because she knew that would want oversight and so that | could contact the family at the earliest opportunity. was pleased to hear that the agreed with her findings and that you were satisfied with the measures that we in place to address matters. This was a particularly sad case and have, since the Inquest, met with Mr Richardson's wife and one of his daughters to offer personal apology and provide ongoing assurance as to the actions that have been taken_ Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff's understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy: have enclosed copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients_ Presenting the guidance in this way was considered to be preferable to any further stand alone policy. It is hoped that this will be highly accessible and provide immediate access to the principles, coupled with signposting to other documents if more information is required. Chair: Peter Molyneux Chief Executive: Samantha Allen Head office: Sussex Partnership NHS Foundation Trust, Swandean;, Arundel Road, Worthing, West Sussex, BN13 3EP M sussexpartnership nhs uk teaching trust of Brighton and Sussex Medical School May Jury put key
hope that the content of the enclosed addresses your concern and provides you with complete reassurance. However; if any further clarification is required or can assist further in any way then please do not hesitate to contact me_
Sent To
- Sussex NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
3 May 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 4th February 2018, I commenced an investigation into the death of John Peter RICHARDSON, aged 60 years. The investigation concluded at the end of the inquest on the 18th December 2018. The Inquest was held with a Jury and they provided the following Narrative conclusion.
Since the 15th January 2018, John Richardson had been an informal patient at Maple Ward, Meadowfield Hospital, Worthing; being treated for Recurrent Depressive Disorder and Adjustment Disorder with suicidal thoughts. Although we acknowledge John Richardson intended to take his own life and was admitted as a voluntary patient, we conclude that he did not receive adequate support in a number of areas which could have prevented the circumstances leading to his death. We fully agree with Lorraine Biddell’s serious incident review in which she identified 9 key failings; we particularly draw attention to the following: after the initial 72hr care plan, no risk assessment or further care plan was formally created, recorded or communicated for John Richardson; this was not addressed during his stay. Poor oral and written communication and a lack of clarity within that communication, in handovers, care notes and accompanying documents, caused confusion amongst staff and eventually with police following his disappearance. Additionally, minimal communication was made with his family. There was poor record keeping and understanding of trust policy, particularly regarding specific failures to address John Richardson’s ongoing risk, the plans for his care, his leave arrangements and the significant events on the 3rd February.
Since the 15th January 2018, John Richardson had been an informal patient at Maple Ward, Meadowfield Hospital, Worthing; being treated for Recurrent Depressive Disorder and Adjustment Disorder with suicidal thoughts. Although we acknowledge John Richardson intended to take his own life and was admitted as a voluntary patient, we conclude that he did not receive adequate support in a number of areas which could have prevented the circumstances leading to his death. We fully agree with Lorraine Biddell’s serious incident review in which she identified 9 key failings; we particularly draw attention to the following: after the initial 72hr care plan, no risk assessment or further care plan was formally created, recorded or communicated for John Richardson; this was not addressed during his stay. Poor oral and written communication and a lack of clarity within that communication, in handovers, care notes and accompanying documents, caused confusion amongst staff and eventually with police following his disappearance. Additionally, minimal communication was made with his family. There was poor record keeping and understanding of trust policy, particularly regarding specific failures to address John Richardson’s ongoing risk, the plans for his care, his leave arrangements and the significant events on the 3rd February.
Circumstances of the Death
On 15th January 2018, John Peter Richardson (known as Sean) was admitted as a voluntary patient to Meadowfields Hospital. At the time of his admission he had been having suicidal thoughts. At about 10.20am on the 3rd February 2018 Sean had gone out for a walk in the grounds but he did not return. Staff at Meadowfields contacted Police at 1.06pm to report Sean as a missing person. The Police attempted to locate him but without success. On 4th February 2018 a member of public was walking their dog in some woodlands in Patching when they came across the body of Mr Richardson. Police and ambulance were called and death was confirmed by paramedics at 11:09am at the scene. Mr Richardson was found lying on his right side with a ligature around his neck, above him was the other part of the ligature tied around the branch of a tree which appears to have snapped at some point. Police confirmed no suspicious circumstances and no third party involvement.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.