John Walker
PFD Report
All Responded
Ref: 2013-0213
All 1 response received
· Deadline: 16 Oct 2013
Coroner's Concerns (AI summary)
Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
View full coroner's concerns
In the circumstances it is my statutory duty to report t0 you: The consideration of, contribution t0 and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made Properly detailed, and the issues communicated amongst all members of the MDT this may have better informed thinking with regard t0 the observation levels set: It is of concern Ihat tnis risk care plan was neither revisited nor revised.
2) There was no clear rationale provided for changes in observation levels in the notes or any explanation given in wriling as t0 the considerations or risk factors taken into account Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and point of reference for further assessment in light of any change in presentation Or condition: The fact that observation levels only decreased (despite evidence heard at the inquest that Mr Walker was expressing ever darker and suicidal thoughts _in_the_week beiore_his death) 5981872. 1 very The without explanation, remains of concern Whilst was accepted in evidence that the hospital's AWOL policy was robust and activated and implemented appropriately concern was raised by the family with regard to the length of taken before Mr Walker could be declared missing and the police informed_ (4) At the time of the incident the fences surrounding the externa common areas of the ward were of scalable height by any patient determined enough t0 do so_ It is accepted Ihat Ihis has been subsequently addressed
2) There was no clear rationale provided for changes in observation levels in the notes or any explanation given in wriling as t0 the considerations or risk factors taken into account Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and point of reference for further assessment in light of any change in presentation Or condition: The fact that observation levels only decreased (despite evidence heard at the inquest that Mr Walker was expressing ever darker and suicidal thoughts _in_the_week beiore_his death) 5981872. 1 very The without explanation, remains of concern Whilst was accepted in evidence that the hospital's AWOL policy was robust and activated and implemented appropriately concern was raised by the family with regard to the length of taken before Mr Walker could be declared missing and the police informed_ (4) At the time of the incident the fences surrounding the externa common areas of the ward were of scalable height by any patient determined enough t0 do so_ It is accepted Ihat Ihis has been subsequently addressed
Responses
Action Taken
The Trust has revised the documents clinicians are asked to complete to ensure they are less repetitive and better support succinct recording of relevant issues and the fences throughout Langley Green Hospital have been altered to make it much more difficult to get over. (AI summary)
The Trust has revised the documents clinicians are asked to complete to ensure they are less repetitive and better support succinct recording of relevant issues and the fences throughout Langley Green Hospital have been altered to make it much more difficult to get over. (AI summary)
View full response
Dear Mr Wilkinson Re: Inquest into the death of John Leon Naylor Walker 21 2013 Thank you for your letter of 22 August 2013, concerning the Inquest into the sad death of John Walker; and your subsequent Regulation 28 Report. We have now had an opportunity to consider the four areas of concern you have highlighted.
1. Risk care planning It is difficult to respond definitively to your conclusion that the consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient We do acknowledge that some documentation was not of the standard we would expect. In particular; the Risk Care Plan and the Formulation section of the MDT Clinical Review was poor and taking this in isolation could imply insufficient risk care planning: However, think it is important to reinforce the evidence of] Consultant Psychiatrist. She explained that the staff caring for Mr Walker did have a good understanding of his risks ad that these risks were documented in the Acute Care Risk Assessment; Acute Care Screening the daily MDT Evaluation and Progress Notes: The point think you are making is that the identified risks should also have been included in subsequent documents, such as the Risk Care Plan. We completely agree As say; the Risk Care Plan for Mr Walker was poor: In recognition of the importance of documentation and to ensure continued learning and improvement; we have since revised the documents clinicians are asked to complete: This is to ensure are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met: In relation to how the risk care planning might have affected the decision about observations, again, refer to the evidence given by She explained that Mr Walker s risk of impulsivity and low mood was carefully considered and that this was why he was nursed on intermittent, every 30 minutes, observations, which is an enhanced level This was to encourage engagement and to more closely monitor his mental state. Although Mr Walker was ambivalent about the future; he was making some plans and expressing a will to recover: He did not have any of attempting to harm himself while in hospital, and nor did he Chair: John Bacon CB Chief Executive: Lisa Rodrigues CBE Head office: Sussex Partnership NHS Foundation Trust; Swandean, Arundel Road, Worthing West Sussex, BN13 3EP www-sussexpartnership nhsuk May very and they history
ever try to abscond. This was of significant clinical importance to the treating team when assessing which level of observation was appropriate: Reflecting on the information available to them at the time, the clinicians involved do not believe a different level of observation was clinically indicated
2. Documented rationale for the observation level We acknowledge that the rationale for changing the level of observation was not documented_ The expectation is that this must be written down and this is what is stated in the policy. This is very important and our Nurse Consultant has provided training to staff to help ensure this happens more consistently: The point you make about the absence of documented rationale when observation levels do not change is a slightly different issue. Firstly, the use of observation to provide support and to manage risk is something clinicians consider constantly, and SO we would not always expect the rationale to be recorded during periods when the level remains the same: This would only be necessary when there is a significant change in risk; determined by clinical ~staff. When reading Mr Walker s records in isolation and with the benefit of hindsight can see why it may appear as though his risk was changing and think you probably have in mind the last Ward Review when he stated that he had never felt worse. Once more refer t0 the evidence when, in relation t0 this last review; she explained this comment was in the context of wanting to start Lithium and was made early on in the review By the end he appeared more positive and was very much involved in the decisions about his care was aware that there were times when Mr Walker was expressing suicidal thoughts, but he also stated feeling safe on the ward and never expressed to staff a wish to leave even though he was in hospital voluntarily: It was therefore completely unexpected when he absconded, especially in the way he did.
3. AWOL Staff contacted the Police within 50 minutes of them noticing that Mr Walker was missing: This was after a full search of the ward, hospital , and hospital grounds was conducted_ and after attempts were made to contact Mr Walker and his family. It was also the conclusion from our internal investigation that the AWOL policy was implemented appropriately:
4. Fences Opal Ward at Langley Green Hospital is an open ward and so there is no requirement to have fences at a particular height; as would be the case for a secure unit: Had Mr Walker or any other patient at that time been considered a risk of absconding then staff would have taken steps t0 ensure appropriate supervision; this may have included locking the door to the garden: As you know; the fences throughout Langley Green Hospital have been subsequently altered to make it much more difficult to get over. This was done in order to make it possible to always keep the doors to the garden open_ as this promotes a more therapeutic environment: Absconding in the way Mr Walker did we believe was not foreseeable for the reasons already set out:
Mr Walker' $ death came as a shock to all the staff involved in his care. Please be assured that each one has taken time t0 reflect and consider the issues that have arisen including the concerns you have highlighted. hope this reply is helpful. sincerely Ksc Lisa Rodrigues CBE Chief Executive Yours
1. Risk care planning It is difficult to respond definitively to your conclusion that the consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient We do acknowledge that some documentation was not of the standard we would expect. In particular; the Risk Care Plan and the Formulation section of the MDT Clinical Review was poor and taking this in isolation could imply insufficient risk care planning: However, think it is important to reinforce the evidence of] Consultant Psychiatrist. She explained that the staff caring for Mr Walker did have a good understanding of his risks ad that these risks were documented in the Acute Care Risk Assessment; Acute Care Screening the daily MDT Evaluation and Progress Notes: The point think you are making is that the identified risks should also have been included in subsequent documents, such as the Risk Care Plan. We completely agree As say; the Risk Care Plan for Mr Walker was poor: In recognition of the importance of documentation and to ensure continued learning and improvement; we have since revised the documents clinicians are asked to complete: This is to ensure are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met: In relation to how the risk care planning might have affected the decision about observations, again, refer to the evidence given by She explained that Mr Walker s risk of impulsivity and low mood was carefully considered and that this was why he was nursed on intermittent, every 30 minutes, observations, which is an enhanced level This was to encourage engagement and to more closely monitor his mental state. Although Mr Walker was ambivalent about the future; he was making some plans and expressing a will to recover: He did not have any of attempting to harm himself while in hospital, and nor did he Chair: John Bacon CB Chief Executive: Lisa Rodrigues CBE Head office: Sussex Partnership NHS Foundation Trust; Swandean, Arundel Road, Worthing West Sussex, BN13 3EP www-sussexpartnership nhsuk May very and they history
ever try to abscond. This was of significant clinical importance to the treating team when assessing which level of observation was appropriate: Reflecting on the information available to them at the time, the clinicians involved do not believe a different level of observation was clinically indicated
2. Documented rationale for the observation level We acknowledge that the rationale for changing the level of observation was not documented_ The expectation is that this must be written down and this is what is stated in the policy. This is very important and our Nurse Consultant has provided training to staff to help ensure this happens more consistently: The point you make about the absence of documented rationale when observation levels do not change is a slightly different issue. Firstly, the use of observation to provide support and to manage risk is something clinicians consider constantly, and SO we would not always expect the rationale to be recorded during periods when the level remains the same: This would only be necessary when there is a significant change in risk; determined by clinical ~staff. When reading Mr Walker s records in isolation and with the benefit of hindsight can see why it may appear as though his risk was changing and think you probably have in mind the last Ward Review when he stated that he had never felt worse. Once more refer t0 the evidence when, in relation t0 this last review; she explained this comment was in the context of wanting to start Lithium and was made early on in the review By the end he appeared more positive and was very much involved in the decisions about his care was aware that there were times when Mr Walker was expressing suicidal thoughts, but he also stated feeling safe on the ward and never expressed to staff a wish to leave even though he was in hospital voluntarily: It was therefore completely unexpected when he absconded, especially in the way he did.
3. AWOL Staff contacted the Police within 50 minutes of them noticing that Mr Walker was missing: This was after a full search of the ward, hospital , and hospital grounds was conducted_ and after attempts were made to contact Mr Walker and his family. It was also the conclusion from our internal investigation that the AWOL policy was implemented appropriately:
4. Fences Opal Ward at Langley Green Hospital is an open ward and so there is no requirement to have fences at a particular height; as would be the case for a secure unit: Had Mr Walker or any other patient at that time been considered a risk of absconding then staff would have taken steps t0 ensure appropriate supervision; this may have included locking the door to the garden: As you know; the fences throughout Langley Green Hospital have been subsequently altered to make it much more difficult to get over. This was done in order to make it possible to always keep the doors to the garden open_ as this promotes a more therapeutic environment: Absconding in the way Mr Walker did we believe was not foreseeable for the reasons already set out:
Mr Walker' $ death came as a shock to all the staff involved in his care. Please be assured that each one has taken time t0 reflect and consider the issues that have arisen including the concerns you have highlighted. hope this reply is helpful. sincerely Ksc Lisa Rodrigues CBE Chief Executive Yours
Sent To
- Sussex Partnership NHS Trust
Response Status
Linked responses
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56-Day Deadline
16 Oct 2013
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 6" June 2012 the senior coroner for West Sussex commenced a investigation into the death of JOHN LEON NAYLOR WALKER born 12 September 1940, being age 71 at the date of his death. The investigation concluded at the end of the inquest on 21 May 2012 following two days of evidence (on 3 May and 21 May 2012). The conclusion of the inquest was that Mr Walker had died as result of hanging and that he had taken his own life whilst suffering from depression and anxiety.
Circumstances of the Death
Mr Walker had history of mental health issues which developed in 2006 when he suffered sudden breakdown, altempting two overdoses of prescription medicine He was gradually helped back to full mental health by 2009 and lived reported full and illness free life March 2012. On 19 March 2012 an altercation with neighbour triggered a further breakdown, as a result of which_ via referral t0 Mental health services he was hospitalised as voluntary patient at Langley Green hospital, West Sussex 10 April 2012 with symptoms of depression and suicidal ideation: Langley Green is not Psychiatric Intensive care unit (i.e it is not secure) Dul It does control visitors t0 the wards and monitors its patients Mr Walker stabilised on the ward, which he had described as safe environment where he felt he could be protected from his impulsivity t0 self-harm in times of low mood Despite repeated denials about on-going suicidal ideation, and an apparent improvement in his condition, Mr Walker made further serious and impulsive attempt on his life on 19 April whilst on visit home Mr Walker was subsequently released from the hospital's care on May 2012, under supervision of the Crisis Resolution Team He continued t0 express suicidal thoughts to his family and on 14 May made further opportunistic attempt on his life when his wife was distracted for a period of 1Omins on the phone Following an assessment local hospital (St Richard' s) on 14 Mr Walker was re-admilted_ voluntary patient; to Langley Green on 17 May 2012. He was assessed admission by second year core trainee in Psychiatry, who whilst having sight of his transfer notes could not recall reviewing the e-notes on the system (which would have been her normal practice) and did not have available t0 her notes from Mr Walker $ admission t0 the hospital as were another location for Mr Walker's discharge summary. full assessment was undertaken with Mr Walker in person, but the Dr did not get an opportunity t0 meet or discuss matters with his wife 5981872. 1 unt May: they
The assessment considered the prior attempts on his life and the apparent speed and impulsivity with which they had been undertaken: His playing down of their severity in interview was taken as an indication that his risk was unlikely to have changed quickly and he was admitted on eyesight observations on account of the perceived high risk that he posed to himself. In evidence the Dr felt sure that she would have conveyed the issues over his impulsivity ad speed of action t0 nursing staff , and whilst it was noted in her notes that his risk was difficult t0 assess was clear that the wider picture of these factors had not been fully ascertained evidence had described how she had explained on number 0f occasions t0 tne hospital the fact that Mr Walker was impulsive but that he had good insight into his condition and understood and feared his impulsivity Mr Walker, it was said by his wife described himself frequently as needing t0 be protected and "to be kept safe until his medication worked" The Dr was not aware of comments and specific concerns which had been raised by the family and it appears therefore that these were not effectively conveyed_ It was believed by Ihe Dr however that the nursing staff would have been aware of these matters from previous contact: On 18 May; observations were reduced to 10 minutes.
10. On 19 May risk care plan for Mr Walker was prepared. This was undertaken by temporary charge nurse withoul; it appeared_ wider input from the MDT. nurse the evidence established had not been present at admission The risk care plan was based on admission notes, but was not informed by any wider discussions with the MDT or family-was not recalled as t0 whether it was subsequently discussed with staff. The risk plan was described as only being meant t0 be a 'stop gap' guide for the team, in the belief that a future risk assessment would be undertaken It proved however t0 be only factua recount Of the events leading Up t0 Mr Walker' $ admission; failed to expand or consider ay of the comments raised in the admission assessment and mace no mention of impulsivity, known triggers protective factors r of the speed with which Mr Walker could act, which was of particular concern t0 the family-No further risk assessment was undertaken or risk care plan prepared, although the inquest was not able to establish why-
11. On 19 May observations were reduced t0 15 minutes and on 24 May; were further reduced t0 30 minutes There was no clear indication in the notes as t0 the reasoning for this, cecisions was established being based on MDT discussions recording only the changes in observations and not the rationale_ Observations remained at 30 minutes until June 2012 On June at some point just after 10.30am, following the 30 minute observation; Mr Walker, with the assistance of stool from the common room; scaled 2m fence surrounding the ward'$ courtyara entered the outer gardens of the hospital, scaled further exterior ience and travelled distance of approximately 0.25 miles on foot before coming across secluded area of wood by grazing fields
13. The evidence showed that Mr Walker found length of fencing tape at the location which he used t0 suspend himself from tree at some time between 11 t0 11.15am. Mr Walker was not discovered missing from the hospital until the next observations round for him at 11am The Police were called (following the instigation of the hospital's AWOL policy and thorough search of the hospital) at 11.50am Police confirmed that Mr Walker was discovered by passers-by at approximately 11.15am that morning
The assessment considered the prior attempts on his life and the apparent speed and impulsivity with which they had been undertaken: His playing down of their severity in interview was taken as an indication that his risk was unlikely to have changed quickly and he was admitted on eyesight observations on account of the perceived high risk that he posed to himself. In evidence the Dr felt sure that she would have conveyed the issues over his impulsivity ad speed of action t0 nursing staff , and whilst it was noted in her notes that his risk was difficult t0 assess was clear that the wider picture of these factors had not been fully ascertained evidence had described how she had explained on number 0f occasions t0 tne hospital the fact that Mr Walker was impulsive but that he had good insight into his condition and understood and feared his impulsivity Mr Walker, it was said by his wife described himself frequently as needing t0 be protected and "to be kept safe until his medication worked" The Dr was not aware of comments and specific concerns which had been raised by the family and it appears therefore that these were not effectively conveyed_ It was believed by Ihe Dr however that the nursing staff would have been aware of these matters from previous contact: On 18 May; observations were reduced to 10 minutes.
10. On 19 May risk care plan for Mr Walker was prepared. This was undertaken by temporary charge nurse withoul; it appeared_ wider input from the MDT. nurse the evidence established had not been present at admission The risk care plan was based on admission notes, but was not informed by any wider discussions with the MDT or family-was not recalled as t0 whether it was subsequently discussed with staff. The risk plan was described as only being meant t0 be a 'stop gap' guide for the team, in the belief that a future risk assessment would be undertaken It proved however t0 be only factua recount Of the events leading Up t0 Mr Walker' $ admission; failed to expand or consider ay of the comments raised in the admission assessment and mace no mention of impulsivity, known triggers protective factors r of the speed with which Mr Walker could act, which was of particular concern t0 the family-No further risk assessment was undertaken or risk care plan prepared, although the inquest was not able to establish why-
11. On 19 May observations were reduced t0 15 minutes and on 24 May; were further reduced t0 30 minutes There was no clear indication in the notes as t0 the reasoning for this, cecisions was established being based on MDT discussions recording only the changes in observations and not the rationale_ Observations remained at 30 minutes until June 2012 On June at some point just after 10.30am, following the 30 minute observation; Mr Walker, with the assistance of stool from the common room; scaled 2m fence surrounding the ward'$ courtyara entered the outer gardens of the hospital, scaled further exterior ience and travelled distance of approximately 0.25 miles on foot before coming across secluded area of wood by grazing fields
13. The evidence showed that Mr Walker found length of fencing tape at the location which he used t0 suspend himself from tree at some time between 11 t0 11.15am. Mr Walker was not discovered missing from the hospital until the next observations round for him at 11am The Police were called (following the instigation of the hospital's AWOL policy and thorough search of the hospital) at 11.50am Police confirmed that Mr Walker was discovered by passers-by at approximately 11.15am that morning
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and Langley Green Hospital have Ihe power t0 take such action
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