Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0306, written 2 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jul 2014 |
|---|---|
| Reference | 2014-0306 |
| Deceased | Henry Marsh |
| 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 |
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.
Her Majesty’s Coroner for the 29 Wood Street,
Northern District of Greater London Barnet ENS 4BE
(Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680
Fax 0208 447 7689
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Department of Health
Richmond House
79 Whitehal
London
SW1A 2NS
4 | CIRCUMSTANCES OF THE DEATH
CORONER
| am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater
London
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.
INVESTIGATION and INQUEST
On the 25" June 2012 | opened an inquest touching the death of Henry Marsh , 30
years old. The inquest concluded on the 10" June 2014. The conclusion of the inquest
was “Suicide”, the medical case of death was 1a Polydrug Intoxication
Henry Marsh had multiple diagnoses including Emotionally Unstable
Personality Disorder , Depression, Post Traumatic Stress Disorder,
Alcohol Dependence and Poly Substance Abuse. Mr Marsh was under
the care of the Home Treatment Team at the time of his death.
On the 18" July 2012 Mr Marsh failed fo attend his appointment with his
psychologist who raised concerns with! Mr Marsh's father who found Mr
Marsh unresponsive on his bed at his home.
[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 MATTERS OF CONCERN are as follows. —
The numbers of patients that the Home Treatment Team have under their care were too
many and there were difficulties in holding effective multi —disciplinary meetings when
North London Coroners Court,
Her Majesty’s Coroner for the
Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)
carrying such a large caseload. 1
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 Tuesday 26" August 2014. 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;-
Members of Mr Marsh's family,
North Middlesex University Hospital Trust
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 time of your
response, alpout tte release or the publication of your response by the Chief 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.
>» From Rt Hon Norman Lamb MP Minister of State for Care and Support Department Department of Health of Health Richmond House 79 Whitehall London SW1A 2NA Andrew Walker HM Coroner for the Northern District of Greater London North London Coroner's Court 29 Wood Street Barnet EN5 4BE Dec ie lars, Thank you for your letter to Jeremy Hunt about the death of Mr Henry Marsh. | am responding on his behalf as the Minister responsible for mental health policy. Your report detailed Mr Marsh's multiple diagnoses which included depression, a personality disorder, substance misuse issues, Post Traumatic Stress Disorder and alcohol dependence. The inquest concluded that Mr Marsh committed suicide whilst under the care of the local Home Treatment Team. You are concerned that the team could not function effectively with its current caseload. Home Treatment Teams are commissioned by local Clinical Commissioning Groups (CCGs) and resourcing these teams is therefore a matter for the local CCG. There is, at national level, a very clear evidence base about the optimal effective composition and functioning of Crisis Home Treatment Teams (CHHTs) and this includes the following: e The National Service Framework crisis home treatment policy. e The University College London Child Outcomes Research Consortium National Institute for Health Research programme that advises on effective care models for CHTTs and online learning and three day courses for those commissioning, establishing and implementing CHTTs. « The Royal College of Psychiatrists College Centre for Quality Improvement, a Royal College peer accreditation quality network that has robust evidence based standards against which teams can be judged. e The National Audit Office report on CHTT optimal operational functioning. Department of Health « The North East Strategic Clinical Network’s published standards for crisis care pathways including CHTTs. e Key performance indicators from Monitor and the Care Quality Commission on metrics which CHTTs need to provide to ensure effectiveness. NHS England intends to map this best practice guidance on to the mental health intelligence network in the next phase of its programme of work. There is currently no set timeline for this to take place. In the meantime, NHS England has put a summary of the guidance with relevant links on the Health and Wellbeing website: http://bit.ly/1rQN2UZ | hope that this information is useful and | thank you for bringing the circumstances of Mr Marsh’s death to our attention. LP LaA Arcee, | NORMAN LAMB ——
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