Adam Carter
PFD Report
All Responded
Ref: 2018-0226
All 1 response received
· Deadline: 18 Nov 2018
Coroner's Concerns (AI summary)
Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.
View full coroner's concerns
The MATTER OF CONCERN iS as follows: day and
The concern relates to record keeping: During his independent review of this matter a Consultant Psychiatrist identified some discrepancies within the medical records including the following: Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of: aggression and violence; self harm; suicidal behaviour; absconding; He did not feel that these risks were documented or clearly formulated in the medical notes. He stated that there was very little detail in the documentation as regards Adam's use of his leave nor of care planning of his leave_ The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave: He was unable to find a record of an assessment of Adam'$ clinical state 1bY nursing staff immediately before the period of escorted ground leave on September 2017 as required by trust policy [although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion]: He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence. Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10"h September 2017. The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents' home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However; such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time It is vital that the basis for such decisions is clear from the records. If this does not happen then have a concern that future deaths may result inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them at a handover of that patient's care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist; and why he or she has been granted leave. The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe: Leave may be declined because the staff member unable to access the relevant information decides to err on the side of caution declines leave to the detriment of that patient's progress and the condition of his her mental health and
It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless write a report such as this one future deaths may result: therefore raise the concern, cannot be prescriptive about what action should be taken and make no recommendations but simply raise the issue. At the conclusion of the inquest, indicated to the Properly Interested Persons that proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph of Schedule 5 of the Coroners and Justice Act 2009.
The concern relates to record keeping: During his independent review of this matter a Consultant Psychiatrist identified some discrepancies within the medical records including the following: Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of: aggression and violence; self harm; suicidal behaviour; absconding; He did not feel that these risks were documented or clearly formulated in the medical notes. He stated that there was very little detail in the documentation as regards Adam's use of his leave nor of care planning of his leave_ The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave: He was unable to find a record of an assessment of Adam'$ clinical state 1bY nursing staff immediately before the period of escorted ground leave on September 2017 as required by trust policy [although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion]: He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence. Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10"h September 2017. The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents' home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However; such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time It is vital that the basis for such decisions is clear from the records. If this does not happen then have a concern that future deaths may result inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them at a handover of that patient's care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist; and why he or she has been granted leave. The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe: Leave may be declined because the staff member unable to access the relevant information decides to err on the side of caution declines leave to the detriment of that patient's progress and the condition of his her mental health and
It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless write a report such as this one future deaths may result: therefore raise the concern, cannot be prescriptive about what action should be taken and make no recommendations but simply raise the issue. At the conclusion of the inquest, indicated to the Properly Interested Persons that proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph of Schedule 5 of the Coroners and Justice Act 2009.
Responses
Action Planned
Lancashire Care NHS Trust will prompt nursing teams to fully consider patient risks prior to leave, consider a minor amendment to the Leave Policy by 28 September 2018, pilot leave diaries in secure services, and the Clinical Director will write to consultants and ward managers about these actions by 14 September 2018. The impact of these actions will be included in a clinical audit in January 2019. (AI summary)
Lancashire Care NHS Trust will prompt nursing teams to fully consider patient risks prior to leave, consider a minor amendment to the Leave Policy by 28 September 2018, pilot leave diaries in secure services, and the Clinical Director will write to consultants and ward managers about these actions by 14 September 2018. The impact of these actions will be included in a clinical audit in January 2019. (AI summary)
View full response
Dear Mr Wilson, Adam Carter (deceased) Regulation 28 report to prevent future deaths The Trust acknowledges receipt of your regulation 28 notice dated 12 July 2018. In the notice you raise the following concerns: The poor quality of record keeping, including Mr Carters use of leave, the lack of a completed risk assessment and no evidence of the Leave Authorisation required to grant leave as required under section 17 , prior to Mr Carters escorted leave on the 10 September 2017 . We are committed to delivering the highest quality of care, and we deeply regret on this occasion that there were things that should have been done better: We have used the findings of the inquest and your notice to make improvements in the quality of our care_ We will endeavor to make our documentation of Section 17 leave more robust by requiring teams to document clearly the reasons for the leave, the risks associated with the leave and the progress that patients are making in relation to leave. This is already in accordance with the Code of Practice and our policies and procedures and so in addition we will take the following actions in response to the concerns you have raised: ACTION Risk assessment prior to all leave being taken Once leave has been agreed by the Multi Disciplinary Team, the nursing team on each ward will be prompted to fully consider the patients risks and state Of mind immediately prior to the patient taking this leave, and reminded to document their up to date decision in the clinical record The senior matron and lead nurse will establish how these prompts are implemented by 28 September
2018. Cupporting Health and Wellbeing 01548109 Chair: Mr David Eva Chief Executive: Professor Heather Tierney-Moore OBE MINDFUL EMPLOYER Way Lou, ( 1
NHS Lancashire Care NHS Foundation Trust ACTION 2 - Policy issues Leave that is given regularly to a patient is already discussed and agreed in the context of the Multi Disciplinary Team, and should be documented in the clinical record, however some points around how this is care planned are not currently included in our Leave Policy and so the Mental Health Law Manager will consider a minor amendment to the policy by 28 September 2018. ACTION 3 _ Routine evaluation of Leave How leave went for the patient should already be documented and discussed in the wider MDT forum; in addition a pilot of "leave diaries" is currently taking place in our secure services, if it is found to increase the quality of post leave documentation this will later be rolled out to all wards ACTION 4 Communication The Clinical Director will write to consultants and ward managers about these actions by 14 September 2018 and reiterate the importance of documenting the rationale, risks and benefits for each individual accessing leave_ ACTION 5 - Audit The impact of the above actions will be included in a clinical audit in January 2019. Matrons and ward managers then review the findings from these audits and feed the results back during clinical supervision with their teams_ The standards for this audit will include: AIl patients who have leave granted will have a copy of the Section 17 Leave Authorisation form in their record 2 An assessment of their presentation mental state and or risk assessment must be undertaken on the day leave is to take place. hope this addresses your concerns and wish to assure you that we have implemented measures to prevent similar incidents in the future_ Should you require any further information the Trust will be more than willing to assist:
2018. Cupporting Health and Wellbeing 01548109 Chair: Mr David Eva Chief Executive: Professor Heather Tierney-Moore OBE MINDFUL EMPLOYER Way Lou, ( 1
NHS Lancashire Care NHS Foundation Trust ACTION 2 - Policy issues Leave that is given regularly to a patient is already discussed and agreed in the context of the Multi Disciplinary Team, and should be documented in the clinical record, however some points around how this is care planned are not currently included in our Leave Policy and so the Mental Health Law Manager will consider a minor amendment to the policy by 28 September 2018. ACTION 3 _ Routine evaluation of Leave How leave went for the patient should already be documented and discussed in the wider MDT forum; in addition a pilot of "leave diaries" is currently taking place in our secure services, if it is found to increase the quality of post leave documentation this will later be rolled out to all wards ACTION 4 Communication The Clinical Director will write to consultants and ward managers about these actions by 14 September 2018 and reiterate the importance of documenting the rationale, risks and benefits for each individual accessing leave_ ACTION 5 - Audit The impact of the above actions will be included in a clinical audit in January 2019. Matrons and ward managers then review the findings from these audits and feed the results back during clinical supervision with their teams_ The standards for this audit will include: AIl patients who have leave granted will have a copy of the Section 17 Leave Authorisation form in their record 2 An assessment of their presentation mental state and or risk assessment must be undertaken on the day leave is to take place. hope this addresses your concerns and wish to assure you that we have implemented measures to prevent similar incidents in the future_ Should you require any further information the Trust will be more than willing to assist:
Sent To
- Lancashire Care NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
18 Nov 2018
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
The medical cause of death was recorded as follows: Multiple injuries due to impact of fall The conclusion was one of SUICIDE In paragraph 3 of the Record of Inquest where when in what circumstances Adam came by his death the jury stated as follows: Adam James Carter died on 10 September 2017. time of Adam's death was recorded at 19.03 hours_ at Blackpool Victoria Hospital. Adam suffered multiple injuries as a result of from the Sth floor of Talbot Road car park in Blackpool. Prior to this event; Adam had absconded from the Harbour Mental Health facility during escorted leave Adam was under treatment at the harbour for bi polar affective disorder. He was suffering from mania on admission and appeared to be responding to treatment As the mania was largely under control from mid August onwards Prior to absconding, Adam appeared settled and there was no evidence to suggest that Adam would abscond: He had previously been on 9 periods of escorted leave without incident, and he had not expressed any self harm or suicidal ideation in that period. It is likely that Adam asked a member of the public to call an ambulance on Church Street identified himself as a patient at the Harbour at 17.45 hours, to making his way to the Sth floor of the car park where the event took place We conclude that alcohol and substance abuse played no causal role in his death or the events leading to it
Circumstances of the Death
Adam Carter was confirmed a 1903 hours on 10 September 2017 at Blackpool Victoria Hospital having been transferred there after having reportedly fallen from the 5"h floor of multi-story car park in Blackpool town centre at around 1755 hours earlier that afternoon. and The falling and prior
Some two hours previously Adam had absconded from The Harbour mental health facility in Blackpool as he commenced a period of escorted leave with a member of staff that leave had been granted on the basis that he could leave the building with the staff member but not go beyond the hospital grounds perimeter. In fact CCTV footage showed him running off through the doors of the building and initially being pursued by the staff member who quickly altered other staff and police were contacted. Between Adam making off from The Harbour and the reported fall from a car park there were no sightings of Adam: The only evidence available was that a member of the public rang the ambulance service at re that a call had been made to the ambulance service from Church Street in Blackpool at 17.45 hours that informing a man had approached him and asked he call for an ambulance but that upon him doing so the person had walked off but after informing him that he had absconded from The Harbour and was a mental patient" There is no further reported sighting of Adam until shortly before 6pm when eyewitness reported seeing Adam's body falling to the pavement and one witness had been on the top floor of the car park when he saw Adam at the top of the car park climb over a fence and drop himself over the edge. A subsequent post mortem examination confirmed Adam had died from multiple injuries as a result of impact trauma Adam had a history of involvement with mental health services from approximately 2000. His parents with whom he lived had noticed deterioration in his condition from 12" July 2017 That deterioration continued and he was detained under section 2 Mental Health Act 1983 for a period of assessment [and later detained under section 3 of that Act] Initially detained in a mental health ward in Blackburn he was transferred to The Harbour before the end of July 2017 His therapeutic team felt his condition improved and by mid-August 2017 he began to utilise escorted ground leave and plans were being put in place form him to be discharged to a supported living placement close to his parents' home Adam was known to have expressed suicidal thoughts previously but it was not felt that he had tried to actively harm himself previously_ By 30" August 2017 the therapeutic team felt he was settled, there was no evidence of
Some two hours previously Adam had absconded from The Harbour mental health facility in Blackpool as he commenced a period of escorted leave with a member of staff that leave had been granted on the basis that he could leave the building with the staff member but not go beyond the hospital grounds perimeter. In fact CCTV footage showed him running off through the doors of the building and initially being pursued by the staff member who quickly altered other staff and police were contacted. Between Adam making off from The Harbour and the reported fall from a car park there were no sightings of Adam: The only evidence available was that a member of the public rang the ambulance service at re that a call had been made to the ambulance service from Church Street in Blackpool at 17.45 hours that informing a man had approached him and asked he call for an ambulance but that upon him doing so the person had walked off but after informing him that he had absconded from The Harbour and was a mental patient" There is no further reported sighting of Adam until shortly before 6pm when eyewitness reported seeing Adam's body falling to the pavement and one witness had been on the top floor of the car park when he saw Adam at the top of the car park climb over a fence and drop himself over the edge. A subsequent post mortem examination confirmed Adam had died from multiple injuries as a result of impact trauma Adam had a history of involvement with mental health services from approximately 2000. His parents with whom he lived had noticed deterioration in his condition from 12" July 2017 That deterioration continued and he was detained under section 2 Mental Health Act 1983 for a period of assessment [and later detained under section 3 of that Act] Initially detained in a mental health ward in Blackburn he was transferred to The Harbour before the end of July 2017 His therapeutic team felt his condition improved and by mid-August 2017 he began to utilise escorted ground leave and plans were being put in place form him to be discharged to a supported living placement close to his parents' home Adam was known to have expressed suicidal thoughts previously but it was not felt that he had tried to actively harm himself previously_ By 30" August 2017 the therapeutic team felt he was settled, there was no evidence of
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.
Inquest Conclusion
Adam James Carter died on 10 September 2017. time of Adam's death was recorded at 19.03 hours_ at Blackpool Victoria Hospital. Adam suffered multiple injuries as a result of from the Sth floor of Talbot Road car park in Blackpool. Prior to this event; Adam had absconded from the Harbour Mental Health facility during escorted leave Adam was under treatment at the harbour for bi polar affective disorder. He was suffering from mania on admission and appeared to be responding to treatment As the mania was largely under control from mid August onwards Prior to absconding, Adam appeared settled and there was no evidence to suggest that Adam would abscond: He had previously been on 9 periods of escorted leave without incident, and he had not expressed any self harm or suicidal ideation in that period. It is likely that Adam asked a member of the public to call an ambulance on Church Street identified himself as a patient at the Harbour at 17.45 hours, to making his way to the Sth floor of the car park where the event took place We conclude that alcohol and substance abuse played no causal role in his death or the events leading to it
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Recording Clinical Discussions
Hyponatraemia Inquiry
No person-centred care
Inaccurate and inaccessible patient records
CDI patient information
Vale of Leven Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Provide evidence-based patient information in a comprehensible summary format
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Regularly update and pilot patient information materials with active patient involvement
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
NHS Modernisation Agency to prioritise patient information quality and establish accreditation system
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Develop kitemarking system for reliable internet health information guidance for public
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.