Thomas Jackson

Date of report: 13 November 2018 Ref: 2018-0352 Deceased name: Thomas Jackson Coroners name: Andrew Haigh Coroners Area: Staffordshire (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths | Alcohol, drug and medication related deaths | Mental Health related deaths This report is being sent to: Midlands Partnership NHS Foundation Trust | Department of Health and Social Care

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO:

1. Neil Carr OBE Chief Executive Midlands Partnership NHS Foundation Trust (MPFT) Trust Headquarters St. George's Hospital Corporation Street Stafford $T16 3SR

CORONER

| am Mr Andrew Haigh Senior Coroner for the Coroner Area of Staffordshire South

CORONER’S LEGAL POWERS

| 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.

INVESTIGATION and INQUEST

On 6" September 2016, | commenced an investigation into the death of Thomas Paul Arthur JACKSON, aged 24 years. The investigation concluded at the end of the inquest on 1S‘ November 2018. The conclusion of the inquest was a detailed narrative one with the Cause of Death being:

la) Clozapine Toxicity

Ib) Pneumonia

Il) Treatment Resistant Schizophrenia.

CIRCUMSTANCES OF THE DEATH

Tom was subject to compulsory Mental Health Detention at a secure unit within St George's Hospital, Stafford. In the early hours of 25" August 2016 Tom was found in a poorly state in his room. He was certified dead at 02.25 hours.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:

(1) During the hearing it was noted that on a number of occasions record keeping was poor. This can make continuity of care difficult and it can lead to matters being missed. | wonder if the Trust can take any action to improve this.

(2) Itis apparent that patients do benefit from regular ‘ward rounds’ or ‘multi- disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate.

(3) It is clear that Clozapine is a beneficial drug for many patients and that a large number of patients in the care of the Trust do receive this drug. However it appears that many staff are not aware of the significance of this medication particularly when considering potential side-effects and warning signs of deterioration.

(4) | would not wish for patients or their families to be overloaded with paperwork but | wonder if there could be a simple leaflet available to patients and family members covering standard information about treatment generally but including matters such as the dangers of patients smoking whilst they are receiving Clozapine.

(5) | wonder if there needs to be a review of any lone-working policy or procedure with particular reference as to when to enter patients’ rooms.

(6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. | understand there have been some changes since the time of Tom's death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process. Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 8"" January 2019. 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested weeigh Day (solicitors representing Tom's mother and sister),

a a father), Capsticks Solicitors LLP (representing the Midland

Partnership NHS Foundation Trust) and Hogan Lovells International LLP (solicitors

representing Mylan Product Ltd).

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

DATE: 13/11/2018

Andrew A Haigh

HM Senior Coroner for Staffordshire (South) Coroner's Office

No 1 Staffordshire Place

Stafford

ST16 2LP

Tel No: 01785 276127 sscor@staffordshire.gov.uk