Danielle Robinson
PFD Report
All Responded
Ref: 2016-0205
All 1 response received
· Deadline: 27 Jul 2016
Coroner's Concerns (AI summary)
Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.
View full coroner's concerns
That the Therapeutic Engagement and Observation Policy presently adopted by BCUHB is not being rigorously followed by staff with the result that opportunities to escalate the level of observations when required are being missed the
(2) That the current Therapeutic Engagement and Observation Policy there should be reviewed with consideration being given to implementing a system situations where there is a serious event which places a patient at risk of immediate Or imminent harm; that there should be an automatic escalation of observation levels to level 3 or 4 (within eyesight O ar's length respectively) for a designated period and/or one to one engagement with the patient So aS to provide an instant "safety net"
(2) That the current Therapeutic Engagement and Observation Policy there should be reviewed with consideration being given to implementing a system situations where there is a serious event which places a patient at risk of immediate Or imminent harm; that there should be an automatic escalation of observation levels to level 3 or 4 (within eyesight O ar's length respectively) for a designated period and/or one to one engagement with the patient So aS to provide an instant "safety net"
Responses
Action Taken
The University Health Board has reviewed and updated its Therapeutic Engagement and Observation Policy to include the automatic escalation of observations following a serious attempt of self-harm until a full multi-disciplinary team review can take place; the policy will be formally re-launched at a learning event planned for September 2016. (AI summary)
The University Health Board has reviewed and updated its Therapeutic Engagement and Observation Policy to include the automatic escalation of observations following a serious attempt of self-harm until a full multi-disciplinary team review can take place; the policy will be formally re-launched at a learning event planned for September 2016. (AI summary)
View full response
Dear Mr Gittins
In response to the Regulation 28, issued on May 28th 2016 as a result of the inquest into the death of Miss Danielle Rhian Robinson. I can confirm that the BCUHB Therapeutic Engagement and Observation Policy has been reviewed and updated to include the automatic escalation of observations following serious attempt of self-harm until a full multi-disciplinary team (MDT) review can take place, a copy is enclosed for your information.
Roles and responsibilities of all staff are clearly detailed within the policy. In relation to the ongoing monitoring of compliance, an audit process is included which will now form part of the divisional audit cycle with outcomes and suggestions for improvements formally reported through our divisional governance structure to QSE.
The division has its first learning event planned for September 2016 and the policy will be formally re-launched at this event.
In response to the Regulation 28, issued on May 28th 2016 as a result of the inquest into the death of Miss Danielle Rhian Robinson. I can confirm that the BCUHB Therapeutic Engagement and Observation Policy has been reviewed and updated to include the automatic escalation of observations following serious attempt of self-harm until a full multi-disciplinary team (MDT) review can take place, a copy is enclosed for your information.
Roles and responsibilities of all staff are clearly detailed within the policy. In relation to the ongoing monitoring of compliance, an audit process is included which will now form part of the divisional audit cycle with outcomes and suggestions for improvements formally reported through our divisional governance structure to QSE.
The division has its first learning event planned for September 2016 and the policy will be formally re-launched at this event.
Sent To
- Betsi Cadwaladr University Health Board
Response Status
Linked responses
1 of 1
56-Day Deadline
27 Jul 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 20th November 2014 commenced an investigation into the death of Danielle Rhian Robinson aged 21_ The investigation concluded at the end of the Inquest held with a jury on the 25th of May 2016_ The conclusion of the Inquest was that Miss Robinson's death was the result of Misadventure The medical cause of death was I(a) Post Cardiac Arrest Hypoxic Brain Injury with Cerebral Oedema due to 1(b) Ligature Strangulation
Circumstances of the Death
Miss Robinson was a 21 year old who was detained under s.3 of Mental Health Act at the Heddfan Unit of Wrexham Maelor Hospital. During the time she was a patient at Heddfan she had repeatedly self harmed, primarily by the placing of ligatures around her neck_ (2) On the 13th of November 2014 she was found unresponsive in her room with a ligature around her neck: At this time, despite earlier episodes of both self harm and absconding from the unit she was on level 1 observations (being every three hours): Despite resuscitation attempts and subsequent treatment she died on the 16th of November 2014_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.