Date of report: 31/01/2023
Deceased name: Samantha Boazman
Coroner name: Fiona Butler
Coroner Area: Leicester City and South Leicestershire
Category: Suicide (from 2015)| Mental Health related deaths
This report is being sent to: Inmind Healthcare Group
|REGULATION 28 REPORT TO PREVENT DEATHS|
|THIS REPORT IS BEING SENT TO: Inmind Healthcare Group|
I am Miss Fiona Butler, His Majesty’s Assistant Coroner for the coroner area of Leicester City and South Leicestershire
|2||CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
|3||INVESTIGATION and INQUEST
On 29 October 2021, I commenced an investigation into the death of Samantha Jane BOAZMAN aged 54. The investigation concluded at the end of a 10 day inquest on 27 January 2023. The conclusion of the jury was: ‘Death by misadventure. We find that there was gross neglect due to a continuous sequence of shortcomings, including a lack of adequate training on the risks and triggers of patients. Failure to remove ligature risks from bedrooms. Inadequate induction and training of temporary staff’.
|4||CIRCUMSTANCES OF THE DEATH
Samantha Boazman had a diagnosis of Emotionally Unstable Personality Disorder and Dissocial Personality Disorder. She had had a 35 year history with mental health services. Samantha arrived at Sturdee Community Hospital (a locked female rehabilitation ward) in June of 2020, when her community placement had broken down and she could no longer be safely managed within the community.
At the time of her death, Samantha was detained under s.3 of the Mental Health Act.
On 17th September 2021 whilst on s.17 leave Samantha walked in front of a slow-moving vehicle, she was admitted to A&E with a minor injury to her knee and head injury where she had fallen backwards. She was discharged the same day. On return to Sturdee Community Hospital Samantha was placed on 15 minute observations but was found in her bathroom Samantha was moved to a safety room.
On 14th October 2021 Samantha returned to her normal bedroom, room 5.
As far as the purpose of conducting observations, the evidence of the healthcare assistants was that they needed to observe that the patient was safe and if the patient was sleeping, to check if the patient was breathing. Health care assistants were to record the location and what the patient was doing and also to record if the healthcare assistant interacted with the patient and anything else meaningful. If a patient was engaged with something (eg: watching tv) there wasn’t an expectation to disturb the patient to interact with them.
During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows: (brief summary of matters of concern)
1. Emergency Response
I heard during the course of the inquest that when an alarm sounded staff would attend the location of the alarm, assess the situation and then go and collect what equipment may be necessary to deal with the emergency.
At the time of Samantha’s death there was only 1 emergency bag for the entire hospital (which had 2 wards and separate self-contained flats on the site). This has now been rectified and there is an emergency bag for every ward.
Staff partake in a drill and evidence provided to me for the purposes of Regulation 28 showed that response times of staff remain at 2 minutes to a patient’s side.
However, I was told that the emergency response still has staff attend a patient, assess and then go and collect the emergency bag, rather than taking it immediately to the patient’s side.
I was provided with evidence for the purposes of Regulation 28 by Inmind Healthcare Group which showed, for example, that in December of 2022 there were 64 incidents, 45 of which were self-harm, 2 of which were clinical incidents. 16 resulted in actual harm and a large number of those incidents concerned patients ligating.
To continue with an emergency response which delays the provision of life saving equipment to the patients’ side is unsafe and in my opinion could lead to future deaths.
The delay in providing CPR to Samantha on balance had no causative effect on her death, but it could for another patient.
2. Observation Policy
At the time of Samantha’s death observations were conducted and recorded in a predictable and prescriptive way by healthcare staff. The quality of observations recorded at the time of Samantha’s death were such that they did not accord with the expectation of the policy and merely recorded where the patient was and what they were doing.
Effective observations were acknowledged as being a vital tool to assess and manage the risk of a patient.
Inmind Healthcare Group’s new observation Policy states:
‘Observations are a therapeutic intervention aimed at reducing factors which contribute to increased risk and promoting recovery. The use of enhanced observation levels should never be regarded as routine practice…….
Observation practice must focus on engaging the person therapeutically and enabling them to address their difficulties constructively. Our interactions must seek to create rapport which allows those in our care to feel valued and safe to share their experiences with us’.
Since Samantha’s death changes have been made by Inmind Healthcare Group to their policy and practice, in that observations are now recorded at the precise time they are conducted and are infrequent in their predictability (eg: hourly observation should be conducted once hourly rather than on the hour every hour).
Evidence of recent observation records demonstrated that this was now practice.
However, there was a disconnect between the new policy and the pre-printed forms being used to record observations; what staff were being instructed to do and what they were recording. This was confusing and the evidence produced did not support the expectations of the new policy or demonstrate it had become embedded practice. The evidence produced did not support a change in staff recording quality observations, so that whilst precise and intermittent timings were evidenced, beyond the location of the patient or what they were doing, the actual presentation of the patient was not being recorded.
|6||ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by March 27, 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
|8||COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
i. The family of Samantha Boazman
iv. Care Quality Commission I have also sent it to
East Midlands Ambulance Service who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
|9||Dated: 31/01/2023 Miss F BUTLER His Majesty’s Assistant Coroner for Leicester City and South Leicestershire|
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