Thomas Thurling
PFD Report
All Responded
Ref: 2015-0309
All 1 response received
· Deadline: 5 Oct 2015
Coroner's Concerns (AI summary)
Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental health deterioration due to staff shortages, posed significant risks.
View full coroner's concerns
(1) On 13 August 2014 Mr Thurling's medication was changed to help his low mood and anxiety_ The Psychiatrist specifically stated that the change in medicalion was to be monitored t0 include the involvement of the CRHT Team One Psychiatrist gave evidence (which was read) that the change in medication was closely monitored by Mind. Mr Thurling later declined any input from the CRHT Team. His Care Co-Ordinator was unaware of the symptoms to look for: Despite close involvement; Mr Thurling's family were unaware of the change in medication and the request for monitoring_ Although Mr Thurling was seen daily by Mind were unaware of any change in medication and the request for monitoring An Out Patient Review was not arranged until 6 weeks later: Following that Out Patient Review the Care Co-Ordinator was absent from work on planned and unplanned leave_Nothing was put in place_to monitor_the medication July entry they
(2) Care Co-ordinator was on planned and unplanned leave from end September 2014 until time of Mr Thurling's dealh: Her Line Managers were aware of this continuous absence. Prior to this there had been a general deterioration in Mr Thurling's mental health noted, he was clearly expressing suicidal ideation, He had attended A & E with thoughts of suicide and he had bought a penknife and cut his neck. His mother had contacted MH Team expressing her concerns on at least 2 occasions_ The Care Co-Ordinator had recommended a Nurse be appointed. Mr Thurling had a known fear of being abandoned by his family and MH Services: Mr Thurling was not reviewed during this period. No alternative Care Co-Ordinator was appointed.
(3) It is clear from evidence given at the inquest that there is a shortage of staff at the Trust. are taken to try and address this but it is unclear a8 to what is being done in the meantime t0 cope with the difficulties that arise as a result.
(2) Care Co-ordinator was on planned and unplanned leave from end September 2014 until time of Mr Thurling's dealh: Her Line Managers were aware of this continuous absence. Prior to this there had been a general deterioration in Mr Thurling's mental health noted, he was clearly expressing suicidal ideation, He had attended A & E with thoughts of suicide and he had bought a penknife and cut his neck. His mother had contacted MH Team expressing her concerns on at least 2 occasions_ The Care Co-Ordinator had recommended a Nurse be appointed. Mr Thurling had a known fear of being abandoned by his family and MH Services: Mr Thurling was not reviewed during this period. No alternative Care Co-Ordinator was appointed.
(3) It is clear from evidence given at the inquest that there is a shortage of staff at the Trust. are taken to try and address this but it is unclear a8 to what is being done in the meantime t0 cope with the difficulties that arise as a result.
Responses
Action Planned
The Trust is sharing the issue of monitoring medication changes with a range of leads, including Pharmacy and those leading Triangle of Care; clinical services have been directed to consider how they are consistently meeting guidance for covering staff absences. (AI summary)
The Trust is sharing the issue of monitoring medication changes with a range of leads, including Pharmacy and those leading Triangle of Care; clinical services have been directed to consider how they are consistently meeting guidance for covering staff absences. (AI summary)
View full response
Dear Ms Lake Regulation 28 report following the inquest of Mr Thomas Thurling write in response to your report dated 6 August 2015. Under paragraph 7 , Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of (he inquest into lhe death of Mr Thomas Thurling on 28
2015. You identified three matters of concern: address Ihese in order: Monitoring of medication changes You identified concern regarding the systems and process employed to monitor the efficacy and safety of medication following a change in prescription: You highlighted that other people in Mr Thurling's care were unaware of the change and how (hey could contribute to monitoring: Additionally, the Trust's staff member had planned and unplanned leave, further contributing to the situation: The Trust recognises that changes in medication are a significant stage in an individual's treatme and require monitoring in order to ensure it is having anticipated effects and be ready to respond,to possible side effects In considering the means by which to ensure this practice is consistent; no single action will provide assurance: Recognising lhe task involves technical knowledge of medication and an understanding of the need to communication to the wider group of people involved in supporting the service user, we are sharing Ihe issue with range of leads in specific areas, such as Pharmacy and {hose leading the implementation of Triangle of Care, as well as clinical teams. will use this direction to cascade learning_ Further, (he matter will be raised directly with clinical staff via internal communications and clinical forums _ Chair: Page Chlef Executive: Mlchael Scott MINDFUL Trust Headquarters: Hellesdon Hospital, Stonewall 2 EMPLOYER Drayton High Road, Norwich, NR6 SBE DIvERSMY CHAMFIOM Tel: 01603 421421 Fax: 01603 421440
W Tsa {i: July will key the They Abour Gary Ative_ 1 DISABl;
Ms Lake J2- Positively, many of our inpatient services have processes in place where (he Pharmacy directly assist with providing information on medication to service users and their families. They also host a medicines information helpline which is available for service users and carers t0 use_ The most direct means by which the Trust will know it is consistently involving all parties in communicalion of changes to the service user's treatment is lhrough measures such (he patient survey, incident reporting and complaints. The Trust will monitor specifically for this type of report taking remedial action where required_ Care Coordinator and staffing have linked your second and third matters of concern because (hey overlap. You registered concern at (he arrangements to cover planned and unplanned absence of staff and how this contributes lo the experience and safety for service users. In respect of cover for planned and unplanned absence of staff; the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e: colleague completing visits and contacts: Clinical services have been directed to consider how they are consistenlly meeting lhis guidance with feedback and further direction via Ihe Trust's Quality Governance Committee_ In addition to these arrangements, the Trust's community services employ a duty worker system, which means that a member of staff from the team will always be available for service users or family to contact. can respond to issues requiring urgent action or pass information to the care coordinator. Contributing to the ability to apply this guidance is the slaffing levels within a team, with some areas experiencing significant pressures. The Trust is taking aclive steps to recruit to these areas but we have found our experiences and challenges are shared across Ihe health sector: The Trust is taking steps to miligate the risks by employing temporary staffing for defined periods of time. This supports an element of consistency, however; our priority is to fill our vacancies with permanent staff. This is an area of focus for the Trust's Executive and your concern mirrors ours: Thank you for bringing the matters to the Trust's attention. If | can be of any furlher assistance please do not hesitate to contact me_
2015. You identified three matters of concern: address Ihese in order: Monitoring of medication changes You identified concern regarding the systems and process employed to monitor the efficacy and safety of medication following a change in prescription: You highlighted that other people in Mr Thurling's care were unaware of the change and how (hey could contribute to monitoring: Additionally, the Trust's staff member had planned and unplanned leave, further contributing to the situation: The Trust recognises that changes in medication are a significant stage in an individual's treatme and require monitoring in order to ensure it is having anticipated effects and be ready to respond,to possible side effects In considering the means by which to ensure this practice is consistent; no single action will provide assurance: Recognising lhe task involves technical knowledge of medication and an understanding of the need to communication to the wider group of people involved in supporting the service user, we are sharing Ihe issue with range of leads in specific areas, such as Pharmacy and {hose leading the implementation of Triangle of Care, as well as clinical teams. will use this direction to cascade learning_ Further, (he matter will be raised directly with clinical staff via internal communications and clinical forums _ Chair: Page Chlef Executive: Mlchael Scott MINDFUL Trust Headquarters: Hellesdon Hospital, Stonewall 2 EMPLOYER Drayton High Road, Norwich, NR6 SBE DIvERSMY CHAMFIOM Tel: 01603 421421 Fax: 01603 421440
W Tsa {i: July will key the They Abour Gary Ative_ 1 DISABl;
Ms Lake J2- Positively, many of our inpatient services have processes in place where (he Pharmacy directly assist with providing information on medication to service users and their families. They also host a medicines information helpline which is available for service users and carers t0 use_ The most direct means by which the Trust will know it is consistently involving all parties in communicalion of changes to the service user's treatment is lhrough measures such (he patient survey, incident reporting and complaints. The Trust will monitor specifically for this type of report taking remedial action where required_ Care Coordinator and staffing have linked your second and third matters of concern because (hey overlap. You registered concern at (he arrangements to cover planned and unplanned absence of staff and how this contributes lo the experience and safety for service users. In respect of cover for planned and unplanned absence of staff; the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e: colleague completing visits and contacts: Clinical services have been directed to consider how they are consistenlly meeting lhis guidance with feedback and further direction via Ihe Trust's Quality Governance Committee_ In addition to these arrangements, the Trust's community services employ a duty worker system, which means that a member of staff from the team will always be available for service users or family to contact. can respond to issues requiring urgent action or pass information to the care coordinator. Contributing to the ability to apply this guidance is the slaffing levels within a team, with some areas experiencing significant pressures. The Trust is taking aclive steps to recruit to these areas but we have found our experiences and challenges are shared across Ihe health sector: The Trust is taking steps to miligate the risks by employing temporary staffing for defined periods of time. This supports an element of consistency, however; our priority is to fill our vacancies with permanent staff. This is an area of focus for the Trust's Executive and your concern mirrors ours: Thank you for bringing the matters to the Trust's attention. If | can be of any furlher assistance please do not hesitate to contact me_
Sent To
- Norfolk and Suffolk NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
5 Oct 2015
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 31 October 2014 commenced an investigation into the death of THOMAS THEO CHARLES THURLING, age 36. The investigation concluded at Ihe end of the inquest on 2015_ The conclusion of the inquest was medical cause of death: Ia) Asphyxiation and CONCLUSION: Mr Thurling took his own life. His intention at the time is not known
Circumstances of the Death
Mr Thurling was showing increasing signs of depression and anxiety: A member of Mind went to see him on 27 October 2014 at his home but there was no response. On 28 October 2014 another member of Mind went to his home_ On receiving no response Police were called and gained to his home Mr Thurling was found clearly dead:
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.