UK Inquiry Tracker

Polly Carpenter

PFD Report All Responded Ref: 2014-0469

Date of Report 28 October 2014

Coroner Elizabeth Earland

Coroner Area Exeter & Great Devon

Response Deadline est. 23 December 2014

Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 23 Dec 2014

Coroner's Concerns (AI summary)

The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.

View full coroner's concerns

_ (1) The Evidence of Named Nurse system which was in operation at the time of Polly's death indicated its execution to be somewhat nebulous_ am encouraged byl vidence that the Trust has taken up the challenge and instituted new steps with 1:1 time and the placement of a ward board with names of nurses allocated to each patient so improving patients access to them: (2) The reduction in AWOLS (absences without leave) is good evidence, that the two pronged approach of ++ engagement with patients on a clinical level and the decision to change the windows out to improve security is working: (3) While note that Risks Assessments were dynamic and said to be performed regularly there was no written record of them appearing on the RIO and staff appeared to have very little or no knowledge of the levels of risk at the instant in time_ (4) The decision not to formally record levels of observations and nurse allocation to do them on the RIO record remains a cause for concern_ From the Evidence heard it is quite clear there can be no audit of a system which is not routinely recorded and some participants remain worryingly vague about the tasks they maylmay not have performed. This does not support the view that being in hospital means that a regular robust system of care and attention is given to patients who desperately need the help for which they have been admitted. It is hoped that provision of a permanent record; would allow a culture of individual responsibility to flourish in the minds of all the nursing staff;

Responses

Devon Partnership NHS Trust NHS / Health Body

27 Jan 2015

Action Taken
Level 2 observation forms are stored for two years, and uploaded if an incident occurs. Level 3 observation levels are entered straight on to the RiO progress notes. Revised documentation including space for comments has been developed and implemented, with guidance issued on expected content. Local training and supervision is in place to support the implementation of these changes. (AI summary)

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Dear Dr Earland Re: Polly Carpenter Regulation 28 Report to Prevent Future Deaths Thank you for your letter of 5 January 2015 in which you identified a residual concern in relation to the storage of observation documentation and whether are uploaded to the RiO records_ have sought clarification from the service and have detailed below further information which trust will provide the required assurance_ Level and 2 (intermittent) observation forms (hard paper forms) are stored for two years, along with the allocation charts and the shift planners. They are only uploaded if an incident occurs during the period of observation. Therefore in the future should we need access to the observation chart records this will be able to be achieved. In the case of with the new policy in place the observation charts for the previous 24 hours would have been uploaded and all observation charts for the duration of her would have been stored Level 3 and (constant) observation levels are entered straight on to the RiO progress notes at the end of every period of allocation. Revised documentation has been developed and is being implemented which includes room on the form for comments; there are guidelines on what we would expect to see written o these forms_ From this the registered nurse on shift would review the completed forms and provide an update on RiO in the progress notes_ Again guidance will be issued as to what we would expect to see written: The changes to the Supportive observation and engagement policy have been developed with the nursing staff to make them as practical and safe as possible and to ensure that staff time is spent engaging with the patients_ There is local training and supervision in place to support the implementation of these changes hope that this additional information described demonstrates our commitment to the learning we have undertaken: If you require any further information please do not hesitate to contact me_

Sent To

Devon Partnership NHS Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 23 Dec 2014

All responses received

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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 13"h July 2012 commenced an investigation into the death of Polly Elisabeth Jane CARPENTER, Aged 36. The investigation concluded at the end of the inquest on 13th October 2014_ The conclusion of the inquest was a Narrative Conclusion Polly Carpenter took her own life on Sth 2011 She went to the railway line at Ford Bridge one and a half miles from Chard Junction. Between (1.50 pm) and (1.55 pm) she calmly and deliberately sat down, in the 4 foot" between the rails in the knowledge that the Exeter bound diesel locomotive L159 approached (at 85 miles per hour): She had taken alcohol, Death was instantaneous She was suffering from emotionally unstable personality disorder when she absconded from the Cedars Inpatient Open Psychiatric Unit in Exeter, whilst formally detained under Section 3 of the Mental Health Act 1983_ She did so after 09.41 hours on the Sth May 2011, She left via a window in (GF113), or (GF121). An inherent weakness in the security of the windows on the Unit was identified in March 2009. were not inspected daily_ In the days leading up to her death, she suffered increasing intensity of emotions and frustration as she worried about her health and the welfare of her children in the care of her father in the face of her own inability to care for them_ On the 3rd May 2011 she exited the Unit and was found in the grounds in the morning. Later on she tried to tamper with the window of bedroom (GF113). The damage to the window was immediately reported_ She was given the antianxiety drug Lorazepam on 3rd May 2011. She was helped in a referral on 4th May 2011 to the Multiagency juarding hub.
10. She was on Level 1 observations and the door of the Ward was locked. 11_ Later on 4th 2011 she superficially self-harmed.
12. She was notlobserved at 11.00 hours on the Sth May 2011_
13. She was found to missing from the Unit at 11.00 hours. report to the Police was recorded at 11.37 hours on Sth May 2011_ 14_ She absconded in part because the continuing risk of her absconding on Sth May 2011 was not appreciated and appropriate precautions were not put in place.

Circumstances of the Death

Past Medical History Long history of psychotic depression with repeated attempts to take her own life with several admissions to inpatient psychiatric units_ Prescribed medication Venlafaxine; Zopiclone, Diazepam, Ocanzapine: She was admitted to The Cedars Unit,_Wonford House Hospital Exeter,early in 2011_ May They Safegi May

She was reported missing to the Police at 1137 hours on 5/5/11 . The next sighting of her was at 1355 hours that same at the railway at Ford Bridge, approximately 1 1/2 miles from Chard Junction, Chard. A train driver reported that she appeared to deliberately step onto the track and sit down between the rails with her back the oncoming train: The train was travelling at approximately 85 mph when he struck the female: Police and Paramedics attended the scene. Her death was recognised at 1430 hours Property in the name of Carpenter was recovered at the scene_ A post-mortem examination was carried out on 9/5/11 at Yeovil District Hospital. sample of her blood was retained for toxicological analysis_ An Inquest was opened with evidence of identification and adjourned by the Coroner for East Somerset, jurisdiction for the Inquest was transferred to the Coroner for Exeter and Greater Devon;

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_