Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0217, written 20 Aug 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Aug 2013 |
|---|---|
| Reference | 2013-0217 |
| Deceased | Ann Margaret Spearing |
| Coroner | T G Moore |
| Coroner area | Avon |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1 | CORONER
lam Mr. T. G. Moore, Assistant Coroner, for the area of Avon
2 | 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.
[HYPERLINKS]
3 | INVESTIGATION and INQUEST
On 2" August 2011 | commenced an investigation into the death of Ann Margaret
SPEARING, Aged 62. The investigation concluded at the end of the inquest on 30th July
2013. The conclusion of the inquest was "Ann Spearing died of pneumonia and
malnutrition contributed to in part by self- neglect following a bereavement, a move to a
new home, continuing anxiety and dependence issues.
4 | CIRCUMSTANCES OF THE DEATH
The circumstances are, a history of learning difficulties, bereavement and dependency
issues. Living in assisted accommodation with very caring staff.
Reviewed on three occasions by the Mental Health Service but found not to be
suffering from a mental illness, seen by hospital staff when clearly malnourished but
found not to have a medical condition. Referred to and reviewed by the eating
disorders unit but assessed as not having an eating disorder.
5 | 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 concerns are that despite the involvement of all the relevant organisations this
lady was able to precipitate her death by starving herself over a period of many months
leading her GP to predict her death some months in advance. It appears that each of
the relevant organisations had drawn their criteria in such a way as to exclude this lady
from their care. She was always someone else's problem.
There needs to be some method of providing funding in such cases rather than
spending time and money passing the person from one agency to another without any
positive curative action being taken.
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
{AND/OR your organisation] 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 14th October 2013. 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
Persons [and to the LOCAL SAFEGUARDING BOARD (where the deceased
was under 18)]. | have also sent it to [NAMED PERSON] who may find it useful or of
interest.
1am 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 tine of your
response, akout the release or the publication of your response bythe f Coroner.
[DATE] 5 an 20 << ; [SIGNED BY CORONER OOK
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr Moore Assistant Coroner Coroner’s Court The Courthouse Bristol Clinical Commissioning Group Old Weston Road South Plaza Flax Bourton Marlborough Street BS48 1UL Bristol, BS1 3NX Tel: 0117 976 6600 Fax: 0117 976 6601 Minicom: 0117 900 2675 Date: 11 October 2013 Ref: AM/SC Dear Mr Moore | write in response to your letter dated 20" August 2013 in regard of Miss Ann Margaret Spearing (DOB 21.04.49) and your request made under Regulation 28, Report to Prevent Future Deaths, that the Clinical Commissioning Group responds setting out action taken or proposed actions with associated timescales. In this letter we respond to your concerns on the following issues. « That multiple organisations were unable to provide an intervention that successfully managed her eating disorder and self-neglect e That each organisations access criteria were exclusive rather than flexible or person-centred e That there should be a mechanism to provide either a bespoke intervention or transferrable funding to ensure that patients receive appropriate interventions or treatments and that resources are not wasted Miss Spearing moved to Bristol in March 2011, 4 months prior to her death. Prior to this she had lived and received services over a long period of time from South Gloucestershire. The handover to Bristol services was satisfactory, however it was clear at the time of her move to Bristol that her general health and wellbeing had significantly deteriorated and that there were underlying issues that required skilled intervention to resolve. With respect to the issues you have raised | note below that the following actions have been taken together with the outcomes | expect these actions to achieve. Bristol has recently reviewed, redesigned and is currently re-procuring its specialist mental health and learning disability services. This process was undertaken following consultation with users, carers and relevant professionals. It was initiated in response to concerns by ail parties that Bristol's mental health services were neither flexible or If you need this letter in a different format, please telephone the number under the address responsive and that there should be a greater bias towards prevention and providing support closer to the patient's own home. This process has meant that a significantly expanded range of services will be available from October 2014. These will include interventions for patients with complex presentations or medically unexplained symptoms such as Miss Spearing. We already have in place a significantly expanded primary care based psychological therapies service, directly accessible by self or professional referral. We anticipate that the revised services will be more flexible in their approach and easily accessible with both characteristics being key elements of their specification. We also expect the partnership between General Practice and mental health services to be more effective as services will be more accountable to General Practice both operationally, and now that GP's commission the services, via the Clinical Commissioning Group. For your reference further details on the range and breadth of services is available via the following website http:/Avww.bristolccg.nhs.uk/your-health-local-services/mental- health-wellbeing/the-story-so-far.aspx Recognising that some of these changes are almost a year away, we have also undertaken or are about to undertake the following changes during the interim to minimise the risk of a similar situation occurring. These include: The development of Primary Care Liaison; this service was implemented in 2012 as Single Point of Access to secondary mental health services across Bristol and provides: « An effective triage service for people accessing services, determining in a timely fashion the most appropriate service response and ensuring that this response is put in place quickly. « Advice and support for primary care staff to manage service users mental health needs and determine whether a formal assessment is necessary « Determination of the nature & severity of mental health needs with consequent sign posting and pathway facilitation. e Rapid and accessible on-going support & advice to the non-specialist workforce such as GPs A Primary Care Eating Disorder Service, known as ‘First Step’, was launched in July : 2013. First Step is a primary care eating disorders service and acts as a gateway to the | Trust's eating disorders care pathway. It delivers evidence-based treatments such as enhanced Cognitive Behaviour Therapy in all GP surgeries across Bristol. A Primary Care Psychotherapy Service which, following a successful pilot, is being implemented in Bristol. Importantly this service will support people such as Miss Spearing who may present with medically unexplained symptoms, or have a diagnosis or characteristics of a personality disorder, who are not suitable for existing secondary mental health services or those who find it difficult to engage with such services. It will also work with patients with mental health problems who have been discharged from services or do not meet the referral threshold for current primary or secondary services. If you need this letter in a different format, please telephone the number under the address This should reduce the number of people who have a mental health problem not meet the criteria for more traditional mental health services and thus the bull cir care remains with their GP's without always appropriate levels of Specialist mental health support. S To further support GP's and provide timely advice with complex patients such as Miss Spearing, we have piloted an enhanced advice and guidance support scheme to GPs. This includes regular clinician fora and reissuing GPs with contact details for psychiatrists within their local catchment area mental health teams. This has led to an increase in GPs contacting their psychiatrist colleagues directly by phone and email with clinical queries that require advice but not necessarily referral into the triage service for assessment. This has been felt to be a significant improvement to prior arrangements. There is further work aimed at supporting on-going communication between GPs and Bristol psychiatrists, including further service change to ensure all GP practices have a nominated psychiatrist they can link to | do hope that these changes will minimise the likelihood of a similar situation as Miss Spearing's occurring again and that if there are difficulties in professionals and patients accessing the correct support we will have better systems in place to escalate and resolve this. | was saddened to learn of the circumstances of Miss Spearing’s death and hope that our actions above assure you that the Clinical Commissioning Group takes the issue of self-neglect seriously. Yours sincerely, rector fransformation and Quality NHS Bristol CCG if you need this letter in a different format, please telephone the number under the address
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