Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0278, written 5 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Nov 2013 |
|---|---|
| Reference | 2013-0278 |
| Deceased | Roshan Abbas Ladak-Ebrahim |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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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: Department of Health Ministerial Correspondence and Public Enquiries Unit Department of Health Richmond House 79 Whitehall London SW1A 2NS 1 CORONER | am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London. 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. 3 | INVESTIGATION and INQUEST On 15th Day of October 2012 | commenced an investigation into the death of Roshen Abbas Ladak-Ebrahim aged 22 years old. The investigation concluded at the end of the inquest on the 1* day of November 2013 concluding on the 4'" Day of November 2013. The conclusion of the inquest was a narrative conclusion; the medical cause of death was hanging. Narrative conclusion:- On the 6" September 2012 Roshen Abbas Ladak-Ebrahim was referred by the walk in centre to Barnet Primary Health Care Trust who forwarded the urgent referral to the Brent Assessment and Brief Treatment Team. On the 11" September 2012 a nurse contacted Mr Ladak-Ebrahim and an appointment was made for an assessment on the 20" September 2012 the nurse who spoke to Mr Ladak-Ebrahim had spoken to his mother on the 10" September 2012 and was told Mr Ladak-Ebrahim’s history including the episode of self-harm and raised her concerns. On the 20" September 2012 Mr Ladak-Ebrahim was taken by his father for his assessment. Mr Ladak-Ebrahim was prescribed medication by a doctor following a multi- disciplinary meeting after Mr Ladak-Ebrahim was assessed by the nurse. Mr Ladak- Ebrahim was not seen by a doctor and no formal follow up meeting was arranged. Mr Ladak-Ebrahim contacted his GP on the 10" October 2012 and the GP sent a fax to Brent Assessment and Brief Treatment Team requesting an urgent assessment. On the 11" October 2012 at 13.29 hrs a nurse contacted Mr Ladak-Ebrahim by telephone and itis likely at that time he was at an immediate risk of harming himself. The Nurse wanted Mr Ladak-Ebrahim to be seen by a doctor but was told that no doctor was available and a referral was made to the Home Treatment Team. The referral to the Home Treatment Team was not accepted until the nurse spoke to the Home Treatment Team the next day. Mr Ladak-Ebrahim had been found having hanged himself at his home on the evening of the 11” October 2012. CIRCUMSTANCES OF THE DEATH Mr Ladak-Ebrahim had contact with a number of health care professionals and was living at home with his mother. Had Mr Ladak-Ebrahim’s mother been told that he was at an immediate risk of self-harm she would have ensured that he was not left alone. 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. — Consideration to be given to issuing guidance when assessing risk of self-harm. The suggestion at the inquest was to firstly assess and record whether there is an immediate risk of self-harm. If there is no immediate risk of self-harm then the assessment should focus on whether there are any thoughts of self-harm, (recording frequency, duration, intensity etc). Whether there is a plan, (recording the details of the plan or plans, etc) and whether there is an intention to end life. Whether the individual is vulnerable to acting on impulse and any past history. The use of high, medium and low risk were considered unhelpful when assessing risk of self-harm. Consideration to be given to giving guidance to health care professionals on the steps that should be taken to ensure that a patient is kept safe by those looking after the patient. In particular informing those looking after a patient that the patient should not be left alone where there is a concern that the patient is at risk of harming themselves. Evidence heard at the inquest suggested that there was some confusion over whether this advice would breach a patient's confidentiality. Consideration to be given to guidance whereby a doctor working in the community mental health agencies is required to have a consultation with a patient before prescribing medication that carries an increased risk of self-harm when first prescribed and arranges to see the patient again to assess the effect of the medication. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday 2" January 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 Solicitors representing the Mental Health Trust, and Mr Ladak-Ebrahim’s mother. Mr Ladak-Ebrahim’s father and the nurse involved in Mr Ladak-Ebrahim’s care. lam 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 ad or of interest. You may make representations to me, the coroner, at th response, about the release or the publication of your r ponse by th ime of your hief Coroner.
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.
| pee | Department | of Health POC1_ 820980 Mr A Walker From the Rt Hon Jeremy Hunt MP Secretary of State for Health Richmond House 79 Whitehall London SWIA 2NS Tel: 020 7210 3000 Mb-sofs@dh.gsi.gov.uk Senior Coroner North London Coroners Court 29 Wood Street Barnet Ye My, Welly , Thank you for your letter following the inquest into the death of Roshen Abbas Ladak-Ebrahim. In your report you conclude that the medical cause of death was hanging. The deceased had been living at home with his mother and hanged himself at his home on the evening of 11 October 2012. You explain that Mr Ladak-Ebrahim had been in contact with a number of health care professionals and had his mother been told he was at immediate risk of self -harm she would have ensured that he was not left alone. You raise the following concerns and ask that we give consideration to: i) issuing guidance when assessing risk of self-harm which looks at whether there is an immediate risk of self-harm or intention to end life. ii) giving advice to health care professionals on steps to be taken to ensure a patient is kept safe by those looking after the patient. Evidence heard at the inquest suggested there was some confusion over whether this advice would breach a patient’s confidentiality. iii) issuing guidance to doctors working in community mental health about the need for a consultation with a patient before prescribing medication that carries an increased risk of self-harm and a follow-up consultation to assess the effect of the medication. The Government has made a clear commitment in the Health and Social Care Act 2012 to give mental health equal priority with physical health. This commitment is at the heart of Closing the Gap: Priorities for essential change in mental health, the Government’s action plan for mental health which was launched by Nick Clegg on 20th January 2014. This sets out twenty five areas where people can expect to see and experience the fastest changes. This document bridges the gap between our longer-term ambition and shorter term action. It sets out our expectations and shows how changes in local service planning and delivery will make a difference in the next two or three years to the lives of people with mental health. Taking your points in turn: guidance on risk assessment is included in clinical guidelines (CG133 Self-harm: longer-term management) produced by the National Institute for Health and Clinical Excellence (NICE), and issued in November 2011. It is worth quoting a relevant extract. The guidelines state: “A risk assessment is a detailed clinical assessment that includes the evaluation ofa wide range of biological, social and psychological factors that are relevant to the individual and, in the judgement of the healthcare professional conducting the assessment, relevant to future risks, including suicide and self-harm.” Risk assessment tools and scales are usually checklists that can be completed and scored by a clinician, or sometimes the service user, depending on the nature of the tool or scale. They are designed to give a crude indication of the level of risk (for example, high or low) of a particular outcome, most often suicide. The strong advice is, however, that they cannot be used to predict future suicide or repetition of self-harm. Turning to confidentiality, there are clearly times when health care professionals, in dealing with a person at risk of suicide, may need to inform the family about aspects of risk to help keep the patient safe. I agree it is crucial that we address any confusion about how information can be shared. That is why the Department of Health is already working with Royal Colleges and professional organisations to agree a consensus statement designed to promote greater sharing of information with the aim of preventing suicide, within the context of the relevant law. We published this on 17 January at: https://www.gov.uk/government/uploads/system/uploads/attachment data/file/2717 92/Consensus_statement_on_ information _sharing.pdf Relevant guidance already exists on justifications for breaching patient confidentiality. The General Medical Council’s Guidance to Doctors on ae | Department of Health Confidentiality covers disclosures in the public interest and disclosing personal information without consent and specifically states: “Disclosure in the public interest may be justified when: (a) failure to disclose information may put the patient, or someone else, at risk of death or serious harm, or (b) disclosure is likely to help in the prevention, detection or prosecution of a serious crime,” In addition, the Department of Health published supplementary guidance to the NHS Confidentiality Code of Practice (November 2010, Ref 13912) on disclosing confidential information when there is a public interest justification to do so and makes clear to healthcare professionals when it is appropriate to disclose personal information. Finally, in relation to your suggestion of issuing guidance to doctors about prescribing medication to mental health patients that carries an increased risk of self-harm, there is currently comprehensive guidance on prescribing produced by a number of bodies including NICE, the General Medical Council and the British Medical Association. The guidance available specifically addresses how to assess the risk of prescribing a particular medication for individuals at risk of self-harm. Guidance often includes advice directed to patients and carers. ‘You mention that a medication that carried an increased risk of self-harm was involved in this case, but the name is not given. If you could supply this information we might be able to provide further advice about this aspect of the case. I hope that this response is helpful and J am grateful to you for bringing the circumstances of Mr Ladak-Ebrahim’s death to my attention. ‘Gn Havakg Jae JEREMY HUNT
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