Prevention of Future Deaths report: Ian Darwin (6 September 2023)

Summary

On 7 March 2023 the coroner commenced an investigation into the death of Ian Darwin, aged 42. The investigation has not yet concluded and the inquest has not yet been heard. However, during the course of the investigation the inquiries revealed matters giving rise to concern. The coroner concluded that in his opinion there is a risk that future deaths could occur unless action is taken.

Content

Matters of Concern:

Tees Esk and Wear Valleys NHS Foundation Trust (TEWV) routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations, TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths.

The above-mentioned inquest has not been heard; there has been no finding that the present death was attributable to acts or omissions in care.

Although arising in the present investigation, the matter of concern is general and has arisen in the context of other investigations. Despite past assurances that the material circumstances have been addressed, the facts of the present case demonstrate that they continue to exist. On 19 July 2023, Assistant Coroner Janine Richards notified TEWV of the same concern arising from matters revealed by another investigation.

TEWV identified Ian Darwin’s death as a serious incident (SI) for the purposes of The Serious Incident Framework (the Framework). The SI investigation (SII) process, defined in the Framework, was the means employed by TEWV to investigate this SI.

The Framework defines SIs as “events where the potential for learning is so great, or the consequences to patients… so significant that they warrant particular attention to ensure these incidents… are investigated thoroughly… and trigger actions that will prevent them from happening again”. SIs “include acts or omissions in care that result in… avoidable death…”. Further, the “occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm”. SI investigations are the means “to ensure that weaknesses in a system are identified, to understand what went wrong … and what can be done to prevent similar incidents happening again”.

Discussing one of the seven key principles of the SI Investigation - that they be Timely and Responsive - the Framework requires that SIs “must be reported without delay and no longer than 2 working days after the incident is identified”. One of “two key operational changes” introduced in the 2015 update was a single timeframe of 60 working days (from date of initial report) for completion of investigation reports. At an “early meeting” the investigator must “set out a realistic and achievable timescales and outcomes”.

The present case:

• Death occurred on 06.03.23;
• Coroner informed that an investigator was initially appointed in around mid-June 2023;
•  By late June, TEWV were “unable to say” when the investigation would be complete;
• The investigation is now expected to be complete in the week commencing 21.08.23 and its report to be finalised 18.09.23.

The general situation:

• TEWV SI death investigations, at all levels of seriousness, are routinely (if not invariably) significantly delayed and the coroner understands there is no expectation of immediate, or any timetable for eventual rectification.
• In some other cases delay is significantly longer than in the present.
• Such delays affect cases of all levels of seriousness.