“Norfolk and Suffolk NHS Foundation Trust 1”

The coroner’s concerns

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Norfolk and Suffolk NHS Foundation Trust 1. It was agreed at the CETR meeting on 9 August 2017 that Tyla was to be seen by the Eating Disorder Service. He was not seen until 25 October 2017. The evidence was the 11 week delay in seeing Tyla was due to a heavy caseload and the practitioner having to remove other cases from his caseload before he was able to work with Tyla; 2. There was no written up-to-date care and crisis plans in place. The most recent written care plan related to Tyla being an inpatient at the Dragonfly Unit, from where he was discharged on 9 August 2017. The written plans were therefore several months out of date. This is against Trust Policy. Evidence was heard that at a CETR meeting on 6 November 2017 a period of a further 3 months was requested to prepare an up to date written care plan. In the event, and despite the family’s repeated requests for plans in writing, it was decided the care plan could be commenced by 30 November 2017, on the basis Tyla’s input into the Care Plan was important and it would take time to gain his meaningful input. The evidence was that there were oral plans in place which were relayed to the parents (including at times of distress), who continued to request plans in writing. The high level of distress and anxiety within Tyla’s home was recognised. An interim written plan was not considered nor that a written plan may have helped the family in providing support to Tyla. Steps have been taken by the Trust to recognise when up to date written plans are not in place and it is understood staff have undergone some work in improving the quality of care plans. However in this case an active decision was made not to update the written plan for some time. Further the evidence did not reveal any insight into the support a written plan could have given the family to support Tyla. , West Norfolk Clinical Commissioning Group, Norfolk and Suffolk NHS Foundation Trust, Queen Elizabeth Hospital and Norfolk County Council 3. The Review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended a multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust, Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be developed and implemented to train staff on how to apply good non- technical skills (teamwork, leadership, task prioritisation and communication) when responding to an emergency. At the inquest it became clear no steps have been taken to organise this event and there is confusion as to who is responsible for arranging this learning event. The Care providers indicated it was for the West Norfolk Clinical Commissioning Group. The West Norfolk Clinical Commissioning Group do not appear to accept responsibility for organisation of the event. Tyla died on 15 November 2017. The West Norfolk Clinical Commissioning Group Review was published 8 May 2019. No steps have been taken with regard to this learning event, save East of England Ambulance Service Trust who has been in contact with the West Norfolk Clinical Commissioning Group. There is concern that a multi-disciplinary learning event will not be organised and will not take place. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisations have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 November 2019. |, the coroner, may extend the period.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0299

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0