Joanna Bowring
PFD Report
All Responded
Ref: 2016-0027
All 1 response received
· Deadline: 23 Mar 2016
Coroner's Concerns (AI summary)
Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
View full coroner's concerns
(1) The patient and carer left an initial assessment conducted on 4th April 2015 without a clear understanding of the service available and without a care plan (2) Carers were not routinely included in the risk assessment process and their views about the patient and knowledge of the patient were not actively sought (3)Carers were_not advised about any behaviours that might indicate an increased risk of suicide
Responses
Action Taken
The Trust re-launched its carers protocol in February 2016, which includes identifying possible "red flags" and behaviours carers may look out for. An audit of care plans and risk assessments for evidence of carer involvement was also carried out and reported to the Leadership Forum. (AI summary)
The Trust re-launched its carers protocol in February 2016, which includes identifying possible "red flags" and behaviours carers may look out for. An audit of care plans and risk assessments for evidence of carer involvement was also carried out and reported to the Leadership Forum. (AI summary)
View full response
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where that will take place what next steps or assessments need to take place, when; where and for what purpose and so on_ This is something the Liaison Psychiatry have been working on since last year: As of the beginning of February 2016 after every assessment an Initial Action Plan is required to be completed at end of an assessment each service user will have a written outcome so it is to both themselves and their carers what the next steps will be. attach the Initial Action Plan Proforma (IAPP) that is completed for your information. The IAPP has been shared with staff through a newsletter, team meetings and supervision as well as shared with all GP surgeries. The IAPP is currently in the middle of its 12-week trial period with the intention of all feedback reviewed at the end of the trial. 2 Carers were not routinely included in the risk assessment process and their views about the patient and knowledge of the patient were not routinely sought: This is an important issue and one that had been identified by the Trust's internal investigation and which believe ppresented evidence of Trust changes in this regard outlining the following steps that had been taken to the inquest itself: That the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately , That this issue has also been separately discussed by the Trust at its Patient Safety Meetings, with the outcome that the Trust is commissioning a senior psychotherapist with expertise in family therapy to provide bespoke training to the Crisis and Community Mental Health Teams. am pleased to confirm that Nigel Jacobs, Family Inclusion Project Lead; has started to provide training across the Service Line to all front-line staff on working with Families with the intention that it assists staff in engaging with carers The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care_ Medway is one of the two areas where this is being piloted: This is taken forward currently, with the intention that selected individual will need to attend a 4 week residential course, and that it is envisaged that will train others in what they have learned: It was accepted that this was the start of a longer term process_ The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags" and what behaviours carers may look out for. A copy of the Protocol is attached. review and audit will be undertaken in June to ensure that it is implemented appropriately. The Trust has met with Joanna Bowring's family on a number of occasions with the intention of using their experiences to feed into this process_ The learning had been embedded by the Trust in face to face meetings, patient safety meetings, and individual written guidance (including by way of policy update) In February an Audit was carried out of care plans and risk assessments for evidence of Carer involvement: This has been carried out and a report of it provided to the Leadership Forum: enclose recent slides they the clear being prior being they being
setting out the findings of the audit and the steps being in places to increase compliance_ The Service Line is to commission an external Risk Assessment Training company (STORM) to deliver Nationally Recommended Risk Assessment Training Trainors to individuals
3. Carers were not advised about the behaviours which might indicate an increased risk of suicide_ It is hoped that the steps outlined in number 2 above will help address point 3. As explained in evidence this is however a very difficult and case specific point. have liaised with the Medical Director and with other clinical staff who have indicated the difficulty as there is no one "red flag" marker which indicates an increased risk of suicide generally, it is dependent on the patient; but there has been a recognition that this could be useful (in line with the changes indicated above). Yours #ykg Angela McNab Chief Executive Enclosures: Acute Service Line Carers Protocol Action plan in response to PFD Powerpoint presentation to the Leadership Forum on action plan put key
where that will take place what next steps or assessments need to take place, when; where and for what purpose and so on_ This is something the Liaison Psychiatry have been working on since last year: As of the beginning of February 2016 after every assessment an Initial Action Plan is required to be completed at end of an assessment each service user will have a written outcome so it is to both themselves and their carers what the next steps will be. attach the Initial Action Plan Proforma (IAPP) that is completed for your information. The IAPP has been shared with staff through a newsletter, team meetings and supervision as well as shared with all GP surgeries. The IAPP is currently in the middle of its 12-week trial period with the intention of all feedback reviewed at the end of the trial. 2 Carers were not routinely included in the risk assessment process and their views about the patient and knowledge of the patient were not routinely sought: This is an important issue and one that had been identified by the Trust's internal investigation and which believe ppresented evidence of Trust changes in this regard outlining the following steps that had been taken to the inquest itself: That the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately , That this issue has also been separately discussed by the Trust at its Patient Safety Meetings, with the outcome that the Trust is commissioning a senior psychotherapist with expertise in family therapy to provide bespoke training to the Crisis and Community Mental Health Teams. am pleased to confirm that Nigel Jacobs, Family Inclusion Project Lead; has started to provide training across the Service Line to all front-line staff on working with Families with the intention that it assists staff in engaging with carers The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care_ Medway is one of the two areas where this is being piloted: This is taken forward currently, with the intention that selected individual will need to attend a 4 week residential course, and that it is envisaged that will train others in what they have learned: It was accepted that this was the start of a longer term process_ The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags" and what behaviours carers may look out for. A copy of the Protocol is attached. review and audit will be undertaken in June to ensure that it is implemented appropriately. The Trust has met with Joanna Bowring's family on a number of occasions with the intention of using their experiences to feed into this process_ The learning had been embedded by the Trust in face to face meetings, patient safety meetings, and individual written guidance (including by way of policy update) In February an Audit was carried out of care plans and risk assessments for evidence of Carer involvement: This has been carried out and a report of it provided to the Leadership Forum: enclose recent slides they the clear being prior being they being
setting out the findings of the audit and the steps being in places to increase compliance_ The Service Line is to commission an external Risk Assessment Training company (STORM) to deliver Nationally Recommended Risk Assessment Training Trainors to individuals
3. Carers were not advised about the behaviours which might indicate an increased risk of suicide_ It is hoped that the steps outlined in number 2 above will help address point 3. As explained in evidence this is however a very difficult and case specific point. have liaised with the Medical Director and with other clinical staff who have indicated the difficulty as there is no one "red flag" marker which indicates an increased risk of suicide generally, it is dependent on the patient; but there has been a recognition that this could be useful (in line with the changes indicated above). Yours #ykg Angela McNab Chief Executive Enclosures: Acute Service Line Carers Protocol Action plan in response to PFD Powerpoint presentation to the Leadership Forum on action plan put key
Sent To
- Kent and Medway NHS and Social Care Partnership Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Mar 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 4th June 2015 commenced an investigation into the death of Joanna Bowring, 32 years. The investigation concluded at the end of the inquest on 26'h January 2016. The conclusion of the inquest was that Joanna Bowring died on 1st June 2015 on the rail track at Boxley, Kent from injuries sustained as a result of being struck by a high speed train. She committed suicide
Circumstances of the Death
Joanna Bowring had been suffering with depression, paranoid delusions and suicidal thoughts. She was receiving support and treatment from the mental health team in the community. She had last been seen by the team on 28"h May 2015 at which time her mental health was determined to have deteriorated and she had purchased rope from the internet for which she would not give a reason: She had no active suicidal thoughts at the time of the review and was not determined to meet the criteria for a hospital admission: On the 1st June 2015 she committed suicide. There was evidence of significant planning
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.