Neglect by trust contributed to patient death, report finds

The report, published on 26 October, revealed that the trust was at fault in the death of a woman in December 2015.

Patricia Cleghorn, who died from an “intentional overdose”, was in the care of the trust’s home treatment team while waiting for voluntary admission to an inpatient bed. She was administered a controlled drug by an unsupervised healthcare assistant.

The “preventing future death” report said Ms Cleghorn was administered 5mg of diazepam by a healthcare assistant working for the team.

The report said: “This [drug] had a dramatic effect on her which was not appreciated by the healthcare assistant despite questioning by her husband and soon after this she was found collapsed, an ambulance was called but she was declared dead by the paramedics.”

The trust confirmed the HCA was not being directly supervised on this visit and this was not in line with its medicines code.

The document also said Ms Cleghorn was “unlikely” to have died when she did had she been admitted to hospital, and she was left at home “self-medicating” despite “repeatedly stating she would end her life by taking an overdose”.

The report said that no formal risk assessment was made by the trust and the staff involved had failed to appreciate what drugs Ms Cleghorn had available to her.

Following her death, the trust took a number of steps including reminding registered and non-registered clinicians in their crisis and community teams the requirements for:

• “clinical risk assessments regarding risk of self-harm and suicide”;
• “risk assessments regarding medicines management and self-medications”; and
• “safe administration of medication in line with the trust’s medicines code and Nursing and Midwifery Council code, including clarifying the role of non-registered staff in crisis teams to ensure that tasks delegated to them are within their sphere of competence”.

The trust said it will review its medicines code “to ensure that the issues highlighted by our investigation are properly considered and addressed in a revised code”. It has also ensured that patients waiting for access to inpatient beds receive “enhanced care”.

Trust chief executive John Short said while the trust had taken steps to improve the flow of patients through inpatient beds, the availability of acute mental health inpatient beds was a “national issue”. This was raised by the coroner in a letter to the Department of Health, NHS England and the Care Quality Commission.

Mr Short added: “Our trust fully accepted the findings of the inquest into the death of Patricia Cleghorn.

“Following this tragic incident we carried out a thorough investigation which has led to a number of actions to improve the assessment of risk and reinforce requirements for the safe administration of medication by appropriately qualified staff.

“We apologise to Ms Cleghorn’s family for the shortcomings in the care we provided to her and our thoughts remain with them following their loss.”