Matthew Llewellyn-Jones
PFD Report
All Responded
Ref: 2016-0385
All 1 response received
· Deadline: 23 Dec 2016
Coroner's Concerns (AI summary)
Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields for crucial carer/family information on admission.
View full coroner's concerns
_ (1) The Devon Partnership trust acknowledged in inquest that the "locked door" is still breached on occasion, as identified on audit An electronic or sign has been considered to offer clearer indications of when the door should be secured, but not yet trialled or actioned. The door therefore remains an ongoing security risk for the ward. (2Observations when carried out in the context of a secure mental health environment should not be predictable or entirely regular, This is not currently part of the ward policy, although it appeared to be accepted by senior staff at inquest The Trust should consider further measures t0 ensure that training and instruction given to all staff in relation to observations is clear, constantly reinforced, and in with best practise.
(3) A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers andlor family mandatory on admission The importance of this information was readily acknowledged by Trust in their internal inquiry and at inquest electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims in this respect:
(3) A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers andlor family mandatory on admission The importance of this information was readily acknowledged by Trust in their internal inquiry and at inquest electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims in this respect:
Responses
Action Taken
Devon Partnership NHS Trust has locked the doors at the Cedars since the inquest and notified entrances that the door is locked; patients are informed on admission, and LED signs have been ordered. The Entry and Exit Policy is under review to support a locked-door policy and a new Quality Monitoring Review Tool has been created. (AI summary)
Devon Partnership NHS Trust has locked the doors at the Cedars since the inquest and notified entrances that the door is locked; patients are informed on admission, and LED signs have been ordered. The Entry and Exit Policy is under review to support a locked-door policy and a new Quality Monitoring Review Tool has been created. (AI summary)
View full response
Devon Partnership NHSI NHS Trust Response to a Regulation 28 Report to Prevent Future Deaths Matthew Llewellyn-Jones (deceased) Date of Death 16/03/16 _ Inquest held 10 to 13 October 2016 Matter of Concern (1 The Devon Partnership NHS Trust acknowledged in inquest that 'locked door' is still being breached on occasion: An electronic pad or sign has been considered to offer clearer indications of when the door should be secured, but not trialled or actioned: The door therefore remains an on-going security risk for the ward. Actions planned or taken: The locked door and permanently locking has been discussed at our Senior Management Board and it has been agreed that the Entry and Exit Policy is reviewed with a recommendation for locked doors on all of our in-patient units_ The Entry and Exit Policy is under review, it will be revised to support a 'locked door' policy with a clear expectation of how to ensure that the restriction in movement does not impact on individual's right to exit: It is anticipated that policy ratification will be sought at Senior Management Board on 10/2/17 _ The doors at the Cedars have been 'locked' since the inquest Review continues as outlined in the Entry and Exit policy: Entrances to our in-patient units have notification that the door is locked; Patients are informed of the locked door position on admission and process of supportive engagement prior to leave LED signs for doors have been ordered and we are waiting for them to be delivered and installed. These are due to be installed within the next month_ There are signs placed on both doors to the ward stating it is closedllocked and to ring for assistance, these will remain in place In addition to the Matter of Concern (2) Observations when carried out in the context of a secure mental health environment should not be predictable or entirely regular: This is not currently of the ward policy; although it appeared to be accepted by senior staff at inquest The Trust should consider further measures to ensure that training and instruction given to all staff in relation to observations Is clear, constantly reinforced, and in line with best practise The 'Engagement Policy' has been reviewed by the Deputy Director of Nursing and is currently finalised; it has been changed to include the following
6.7 For anyone who requires intermittent engagement and observation, the minimal interval of these must be documented in the care plan, and the actual times of engagement and observation recorded on the relevant form Minimum interval time may start at 5 minutes_ Staff should be mindful to ensuring that observations are neither predictable nor entirely regular (i.e: Person 1, 15 minutes engagement should not be at exact intervals of 15, 30, 45 etc. minutes past the hour:)
the yet the part being
The revised policy will be published in January 2017 across the Trust and will be shared directly with colleagues in the Adult Directorate in its Directorate Bulletin in January 2017. The form used for recording observations had been changed at the time of the inquest and now requires the specific time of observation to be recorded on the form for each patient: A copy of the recording form is attached for information (ref 1.0). New or temporary staff are briefed on team practices as part of their local induction. Compliance with the engagement policy is monitored via the Quality Monitoring Tool; adjustments to the relevant quality areas will be actioned upon ratification of policies: Matter of Concern (3) A new system of note recording has been introduced since this death; but it still does not make obtaining information from carers and / or family mandatory on admission: The importance of this information was really acknowledged by the Trust in their inquiry (RCA) and at inquest The electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims In this respect: The introduction of mandatory field has been considered by the Care Notes team and senior clinical colleagues. The decision has been made not to add as mandatory field, it will continue to be recorded as a 'free text' field. rational for this decision is that mandatory field could be completed with a generic comment for example 'have been unable to contact family at this time'_ when audited as detailed below, this would be identified as completed. If the field is left 'blank' audit will highlight this and allow individual review and follow up with the staff member concerned_ A copy of the Care Notes forms are attached, the specific changes that have been made are- Care Planning (Information sought from carerlfamily) this is now active on the Care Notes system (ref 2.1) Risk Assessment (Specific area looking at carerlfamily views) this is due to become active by the end of January 2017 (ref 2.2) A new single Assessment & Review format for all services is being developed work to date is attached. Implementation date is by end of February 2017 . (ref 2.3) The compliance with this change in practice will be monitored and reported using the new 'Quality Monitoring Review Tool , this focuses on assessing the quality of record keeping as part of delivering overall high quality, safe and effective care. A copy of the Quality Monitoring Review Tool and an example of the Inpatient Team Quality Monitoring RAG feedback report are attached for information (ref 3.1 and 3.2) The 'Quality Monitoring Review Tool is: Teamlservice specific Capable of providing quick clear feedback to teams on their recording quality in Care Provides assurance to LDU Directorate Trust on the quality of recording how noted improvements were progressed
The the Notes
Supports the engagement from the Multi-Disciplinary team (including medical staff) in reviewing and embedding practice change across the team service Methodology A pro-forma has been produced for quality checking, with a range of quality areas pertinent to their service areas. These quality areas are selected and reviewed on rolling basis. Teams use the Quality Review feedback forms to inform practice via team meetings handovers and supervision Teams are provided assurance on impact of feedback via Local Delivery Unit Governance Learning from Experience meetings This information will inform Directorates on themes and trends in clinical record quality and where practice issues might be wider and require corporate involvement; Changes to the care record, such as the indicated plans with risk assessment and assessment review form can be reflected in the proforma ensuring the quality of recording during a period of changed practice. The Quality tool is owned by the services that develop its own proforma's enabling dynamic and responsive changes based on practice change, new innovation or learning from 'experiences' (RCA, Complaint; RMS etc)_ AIl of these actions will be monitored and progress reported through the Adult Directorates Directorate Governance meetings, this progress will be reported to the Trusts Quality and Safety Committee_
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6.7 For anyone who requires intermittent engagement and observation, the minimal interval of these must be documented in the care plan, and the actual times of engagement and observation recorded on the relevant form Minimum interval time may start at 5 minutes_ Staff should be mindful to ensuring that observations are neither predictable nor entirely regular (i.e: Person 1, 15 minutes engagement should not be at exact intervals of 15, 30, 45 etc. minutes past the hour:)
the yet the part being
The revised policy will be published in January 2017 across the Trust and will be shared directly with colleagues in the Adult Directorate in its Directorate Bulletin in January 2017. The form used for recording observations had been changed at the time of the inquest and now requires the specific time of observation to be recorded on the form for each patient: A copy of the recording form is attached for information (ref 1.0). New or temporary staff are briefed on team practices as part of their local induction. Compliance with the engagement policy is monitored via the Quality Monitoring Tool; adjustments to the relevant quality areas will be actioned upon ratification of policies: Matter of Concern (3) A new system of note recording has been introduced since this death; but it still does not make obtaining information from carers and / or family mandatory on admission: The importance of this information was really acknowledged by the Trust in their inquiry (RCA) and at inquest The electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims In this respect: The introduction of mandatory field has been considered by the Care Notes team and senior clinical colleagues. The decision has been made not to add as mandatory field, it will continue to be recorded as a 'free text' field. rational for this decision is that mandatory field could be completed with a generic comment for example 'have been unable to contact family at this time'_ when audited as detailed below, this would be identified as completed. If the field is left 'blank' audit will highlight this and allow individual review and follow up with the staff member concerned_ A copy of the Care Notes forms are attached, the specific changes that have been made are- Care Planning (Information sought from carerlfamily) this is now active on the Care Notes system (ref 2.1) Risk Assessment (Specific area looking at carerlfamily views) this is due to become active by the end of January 2017 (ref 2.2) A new single Assessment & Review format for all services is being developed work to date is attached. Implementation date is by end of February 2017 . (ref 2.3) The compliance with this change in practice will be monitored and reported using the new 'Quality Monitoring Review Tool , this focuses on assessing the quality of record keeping as part of delivering overall high quality, safe and effective care. A copy of the Quality Monitoring Review Tool and an example of the Inpatient Team Quality Monitoring RAG feedback report are attached for information (ref 3.1 and 3.2) The 'Quality Monitoring Review Tool is: Teamlservice specific Capable of providing quick clear feedback to teams on their recording quality in Care Provides assurance to LDU Directorate Trust on the quality of recording how noted improvements were progressed
The the Notes
Supports the engagement from the Multi-Disciplinary team (including medical staff) in reviewing and embedding practice change across the team service Methodology A pro-forma has been produced for quality checking, with a range of quality areas pertinent to their service areas. These quality areas are selected and reviewed on rolling basis. Teams use the Quality Review feedback forms to inform practice via team meetings handovers and supervision Teams are provided assurance on impact of feedback via Local Delivery Unit Governance Learning from Experience meetings This information will inform Directorates on themes and trends in clinical record quality and where practice issues might be wider and require corporate involvement; Changes to the care record, such as the indicated plans with risk assessment and assessment review form can be reflected in the proforma ensuring the quality of recording during a period of changed practice. The Quality tool is owned by the services that develop its own proforma's enabling dynamic and responsive changes based on practice change, new innovation or learning from 'experiences' (RCA, Complaint; RMS etc)_ AIl of these actions will be monitored and progress reported through the Adult Directorates Directorate Governance meetings, this progress will be reported to the Trusts Quality and Safety Committee_
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Sent To
- Devon Partnership Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Dec 2016
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 March 2015 commenced an investigation into the death of Matthew Llewellyn - Jones. The investigation concluded at the end of the inquest on 13 October 2016. The conclusion of the jury was Medical cause of death Hanging Conclusion suicide and narrative We find that there was insufficient assessment of Matthews of self-harm and going AWOL at both the initial assessment meeting on 15" March and ongoing assessment meeting on the 18"h March, to inadequate notice being taken of information available family and other 3"4 parties We find that the level of contact received by Matthew, clinical notes and level of observation were insufficient and inadequate We find no evidence of use of a sign on the door to say that it was locked and that Matthew's ability to exit the door was a failure of the locked door policy: We find that patients going through the locked door into an unsecured area to smoke increased the risk that the locked door policy would fail, and we find no evidence that the Trust took all reasonable steps to reduce that risk We find that the Bank Nurse did not receive adequate induction to the ward or writtenloral guidance as to individual patient risks_ We find that inadequate staffing levels was a contributory factor to failings at all stages of Matthews care and security: 17th risk the due from
Circumstances of the Death
Matthew had a history of mental health issues and these had been managed in the community and with the care of his family: He became suddenly very unwell with psychosis and following mental health assessment was detained under s2 of the Mental Health Act for his own safety and the safety of others_ The following day he was able to leave the locked ward where he was detained unaccompanied His body was discovered over an hour later; hanging by a ligature in the grounds of the hospital.
Action Should Be Taken
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.