Danny Sweet
PFD Report
All Responded
Ref: 2016-wp25341
All 1 response received
· Deadline: 23 Sep 2016
Coroner's Concerns (AI summary)
The coroner questioned whether it was appropriate to presume the best-case scenario for patients presenting inconsistently and whether there should be a check to ensure consistency in treatment decisions; the Serious Incident Report was also incomplete.
View full coroner's concerns
Mr Sweet presented in equivocal and contradictory fashion. Accordingly, he was very difficult to assess and it was equally difficult for clinicians to form a view of the likely risk he posed to himself.
I was concerned, however, that the very day after a Consultant Psychiatrist contemplated informal admission into hospital, a nurse from the HTT felt able to refer Mr Sweet to the Community Mental Health team where he was not seen for a month.
I wondered if it may be appropriate to reflect on how to deal with patients who present in an inconsistent manner. In particular, I questioned whether it was appropriate simply to presume the best case scenario.
I was further concerned whether or not it was appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions. There appeared to be obvious inconsistencies first in the concern of and the decision the very next day to discharge Mr Sweet from the caseload of the HTT and secondly, in the decision of to refer to CMHT yet discharging Mr Sweet from caseload after a first assessment.
Mr Sweet's case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating.
I recognise this is a difficult issue. I wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm. Furthermore, I feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient's deteriorating condition. I recognise there will be an obvious need to respect the rules on confidentiality.
I raise also whether there should be training to ensure that the entries in the notes and records are consistent. By way of illustration, where and decide to discharge Mr Sweet from their respective caseloads, they should justify those decisions in light of s earlier concern that Mr Sweet may need an informal admission into hospital.
A final matter that came out of the inquest was that the Serious Incident Report was incomplete. In particular, neither nor had been formally interviewed as part of the review process. You may feel that there would be merit in getting the respective clinicians from the relevant departments (Hospital Liaison, HTT and CMHT) together to see if there are any lessons to be learned.
I was concerned, however, that the very day after a Consultant Psychiatrist contemplated informal admission into hospital, a nurse from the HTT felt able to refer Mr Sweet to the Community Mental Health team where he was not seen for a month.
I wondered if it may be appropriate to reflect on how to deal with patients who present in an inconsistent manner. In particular, I questioned whether it was appropriate simply to presume the best case scenario.
I was further concerned whether or not it was appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions. There appeared to be obvious inconsistencies first in the concern of and the decision the very next day to discharge Mr Sweet from the caseload of the HTT and secondly, in the decision of to refer to CMHT yet discharging Mr Sweet from caseload after a first assessment.
Mr Sweet's case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating.
I recognise this is a difficult issue. I wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm. Furthermore, I feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient's deteriorating condition. I recognise there will be an obvious need to respect the rules on confidentiality.
I raise also whether there should be training to ensure that the entries in the notes and records are consistent. By way of illustration, where and decide to discharge Mr Sweet from their respective caseloads, they should justify those decisions in light of s earlier concern that Mr Sweet may need an informal admission into hospital.
A final matter that came out of the inquest was that the Serious Incident Report was incomplete. In particular, neither nor had been formally interviewed as part of the review process. You may feel that there would be merit in getting the respective clinicians from the relevant departments (Hospital Liaison, HTT and CMHT) together to see if there are any lessons to be learned.
Responses
Action Planned
The Trust will launch a review of clinical risk assessments for people presenting with suicidal thoughts or acts, particularly focusing on the use of the STORM risk assessment tool. They will also review the Trust's Serious Incident Investigation process. (AI summary)
The Trust will launch a review of clinical risk assessments for people presenting with suicidal thoughts or acts, particularly focusing on the use of the STORM risk assessment tool. They will also review the Trust's Serious Incident Investigation process. (AI summary)
View full response
Dear Mr Cox
Regulation 28 Report to Prevent Future Deaths
I refer to your Regulation 28 Report following the inquest of Danny Sweet. As an organisation our vision is “Delivering high quality care” and therefore we welcome the opportunity to reflect not only your concerns but also the evidence given by during the course of the inquest. We have given careful consideration to your report and our response. We view this as a positive opportunity for the Trust to ensure there is learning.
We have tried to respond to each matter of concern as outlined in your report and detail the action to be taken.
• Is it appropriate to reflect on how to deal with patients who present in an inconsistent manner? Is it appropriate to presume the best case scenario?
We agree that it is appropriate to reflect on how to deal with patients who present in an inconsistent manner. It is not appropriate to presume the best case scenario and clinical staff are trained to use structured risk assessments. However we propose to launch a review into the clinical risk assessment of people who present with suicidal thoughts or acts across each of our services and in particular the Trust’s use of the STORM
Page 2
risk assessment as wider learning across the Trust. We hope to have completed the review by the end of February 2017.
• Is it appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions
It is impossible to ensure consistency in treatment decisions because assessments are “of the moment” and there has to be flexibility for clinicians as situations can change. However, the Trust does recognise that there does need to be a clearly defined pathway decided at the initial presentation. The action that will be taken is that there will be a Learning from Experience meeting. We will ensure that clinical staff, across all services involved in the care of Mr Sweet, participate in the meeting. The meeting will be overseen by Inpatient Clinical Director and Consultant in Rehabilitation Psychiatry. One of the purposes of the meeting will be to consider developing the pathway.
• How the Trust deals with patients who appear to have capacity and yet decline treatment/care where family/friends state their condition is deteriorating.
The Mental Health Act provides the legal framework to deal with patients who have capacity yet decline treatment. In light of your report and Mrs Sweet’s witness statement the Trust acknowledges the need for staff to engage with family and friends in receiving information from them as well as building on the work undertaken by the Trust around the “triangle of care.” The aim would be to ensure that not only are family and friends supported but also informed about services and mental health and involved in the care provided. We recognise the importance of staff engaging with friends and family in their assessments and on-going care. It will be a further purpose of the Learning from Experience Meeting to consider ways of doing this.
• Should clinicians record in the records their concerns that patients have capacity and yet may go on to self-harm? It may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition.
• Should there be training to ensure that the entries in the notes and records are consistent.
The Trust does provide training to staff in relation to record keeping and the importance of recording the rationale for decisions. We are already enhancing the record keeping of staff by implementing the “SBAR” (Situation, Background, Assessment, Recommendation) tool as standard in record keeping. This has been introduced to staff on our psychiatric inpatient wards and we will continue to filter this through across all services. We are therefore making efforts and taking action to introduce a more structured format to our records. This action is on-going.
• The Trust’s Serious Incident report is incomplete.
The Trust acknowledges that the Serious Incident Report is incomplete. There are learning points for the Trust in relation to Serious Incident Investigations and the Trust’s Director of Quality and Governance/Executive Nurse, will take this forward. We will ensure that in the future all key clinicians, within the Terms of Reference, are involved in future investigations. We have also identified the importance of providing feedback to staff interviewed for the purposes of the investigation.
Page 3
In summary there will be action taken by the Trust by way of a Learning from Experience Meeting to consider ways of developing a pathway; how to engage friends and family and to allow a further period of reflection. It is expected that an action plan will be developed at the Learning from Experience meeting. There will also be a review of the clinical risk assessments of people who present with suicidal thoughts or acts by the end of February 2017 and we will review the Trust’s Serious Investigation process.
The Trust is truly saddened by the death of Mr Sweet and wish to extend our condolences to his family.
Regulation 28 Report to Prevent Future Deaths
I refer to your Regulation 28 Report following the inquest of Danny Sweet. As an organisation our vision is “Delivering high quality care” and therefore we welcome the opportunity to reflect not only your concerns but also the evidence given by during the course of the inquest. We have given careful consideration to your report and our response. We view this as a positive opportunity for the Trust to ensure there is learning.
We have tried to respond to each matter of concern as outlined in your report and detail the action to be taken.
• Is it appropriate to reflect on how to deal with patients who present in an inconsistent manner? Is it appropriate to presume the best case scenario?
We agree that it is appropriate to reflect on how to deal with patients who present in an inconsistent manner. It is not appropriate to presume the best case scenario and clinical staff are trained to use structured risk assessments. However we propose to launch a review into the clinical risk assessment of people who present with suicidal thoughts or acts across each of our services and in particular the Trust’s use of the STORM
Page 2
risk assessment as wider learning across the Trust. We hope to have completed the review by the end of February 2017.
• Is it appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions
It is impossible to ensure consistency in treatment decisions because assessments are “of the moment” and there has to be flexibility for clinicians as situations can change. However, the Trust does recognise that there does need to be a clearly defined pathway decided at the initial presentation. The action that will be taken is that there will be a Learning from Experience meeting. We will ensure that clinical staff, across all services involved in the care of Mr Sweet, participate in the meeting. The meeting will be overseen by Inpatient Clinical Director and Consultant in Rehabilitation Psychiatry. One of the purposes of the meeting will be to consider developing the pathway.
• How the Trust deals with patients who appear to have capacity and yet decline treatment/care where family/friends state their condition is deteriorating.
The Mental Health Act provides the legal framework to deal with patients who have capacity yet decline treatment. In light of your report and Mrs Sweet’s witness statement the Trust acknowledges the need for staff to engage with family and friends in receiving information from them as well as building on the work undertaken by the Trust around the “triangle of care.” The aim would be to ensure that not only are family and friends supported but also informed about services and mental health and involved in the care provided. We recognise the importance of staff engaging with friends and family in their assessments and on-going care. It will be a further purpose of the Learning from Experience Meeting to consider ways of doing this.
• Should clinicians record in the records their concerns that patients have capacity and yet may go on to self-harm? It may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition.
• Should there be training to ensure that the entries in the notes and records are consistent.
The Trust does provide training to staff in relation to record keeping and the importance of recording the rationale for decisions. We are already enhancing the record keeping of staff by implementing the “SBAR” (Situation, Background, Assessment, Recommendation) tool as standard in record keeping. This has been introduced to staff on our psychiatric inpatient wards and we will continue to filter this through across all services. We are therefore making efforts and taking action to introduce a more structured format to our records. This action is on-going.
• The Trust’s Serious Incident report is incomplete.
The Trust acknowledges that the Serious Incident Report is incomplete. There are learning points for the Trust in relation to Serious Incident Investigations and the Trust’s Director of Quality and Governance/Executive Nurse, will take this forward. We will ensure that in the future all key clinicians, within the Terms of Reference, are involved in future investigations. We have also identified the importance of providing feedback to staff interviewed for the purposes of the investigation.
Page 3
In summary there will be action taken by the Trust by way of a Learning from Experience Meeting to consider ways of developing a pathway; how to engage friends and family and to allow a further period of reflection. It is expected that an action plan will be developed at the Learning from Experience meeting. There will also be a review of the clinical risk assessments of people who present with suicidal thoughts or acts by the end of February 2017 and we will review the Trust’s Serious Investigation process.
The Trust is truly saddened by the death of Mr Sweet and wish to extend our condolences to his family.
Sent To
- Cornwall Partnership Foundation Trust
Response Status
Linked responses
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56-Day Deadline
23 Sep 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 4 November 2015, an inquest was commenced into the death of Danny Sweet. The inquest concluded at a hearing on 21 July 2016. The medical cause of death was found to be:
1a Fulminant hepatic failure; 1b Paracetamol overdose.
I returned an open conclusion. While I felt it was highly likely that Mr Sweet had taken his own life and intended to do so, I could not be sure of this.
1a Fulminant hepatic failure; 1b Paracetamol overdose.
I returned an open conclusion. While I felt it was highly likely that Mr Sweet had taken his own life and intended to do so, I could not be sure of this.
Circumstances of the Death
Mr Sweet had a long history of mental health issues extending back nearly 20 years.
On 15 September 2015 he was seen in the Emergency Department at Royal Cornwall Hospital Truro following a suspected overdose. He was seen by a Consultant Psychiatrist, who considered whether Mr Sweet should have a Mental Health Act assessment.
concluded that there were no grounds to detain Mr Sweet compulsorily. He considered whether a voluntary admission was appropriate, but instead chose to refer Mr Sweet to the Home Treatment Team.
Mr Sweet was seen the next day by the Home Treatment Team and I heard evidence from who saw Mr Sweet with a colleague.
Notwithstanding the Consultant's misgivings the day before, found Mr Sweet to be much improved. He felt there was no need for involvement by the HTT and elected to refer Mr Sweet to the Community Mental Health team.
Mr Sweet was subsequently seen by on 16 October, that is to say, one month after the assessment by Mr Sweet told he was much improved and did not need any input from CMHT. Accordingly, discharged him from the caseload.
Subsequently, Mr Sweet told an out of hours worker that he had misled and that, in fact, his true condition was worse than he had led her to believe. A duty worker subsequently contacted Mr Sweet who, yet again, gave a contrary indication and said that he did not require any assistance.
On 23 October (one week after discharge from the CMHT workload) Mr Sweet took a staggered overdose of paracetamol and died the next day in Treliske hospital.
On 15 September 2015 he was seen in the Emergency Department at Royal Cornwall Hospital Truro following a suspected overdose. He was seen by a Consultant Psychiatrist, who considered whether Mr Sweet should have a Mental Health Act assessment.
concluded that there were no grounds to detain Mr Sweet compulsorily. He considered whether a voluntary admission was appropriate, but instead chose to refer Mr Sweet to the Home Treatment Team.
Mr Sweet was seen the next day by the Home Treatment Team and I heard evidence from who saw Mr Sweet with a colleague.
Notwithstanding the Consultant's misgivings the day before, found Mr Sweet to be much improved. He felt there was no need for involvement by the HTT and elected to refer Mr Sweet to the Community Mental Health team.
Mr Sweet was subsequently seen by on 16 October, that is to say, one month after the assessment by Mr Sweet told he was much improved and did not need any input from CMHT. Accordingly, discharged him from the caseload.
Subsequently, Mr Sweet told an out of hours worker that he had misled and that, in fact, his true condition was worse than he had led her to believe. A duty worker subsequently contacted Mr Sweet who, yet again, gave a contrary indication and said that he did not require any assistance.
On 23 October (one week after discharge from the CMHT workload) Mr Sweet took a staggered overdose of paracetamol and died the next day in Treliske hospital.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.