Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0309, written 3 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 | 3 Jul 2014 |
|---|---|
| Reference | 2014-0309 |
| Deceased | Helena Farrell |
| Coroner | Ian Smith |
| Coroner area | Cumbria (South & East) |
| Category | Community health care and emergency services related deaths |
| Organisation named | Cumbria Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. 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. Chief Executive, Cumbria Partnership NHS Foundation Trust 2. Chief Executive, Cumbria County Council 1 CORONER I am Ian Smith, Senior Coroner, for the coroner area of South & East Cumbria 2 CORONER’S LEGAL POWERS I 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 10 January 2013 I commenced an Inquest into the death of Helena Kathleen Farrell, date of birth: 20 February 1997. The investigation concluded at the end of the inquest on 30th June 2014. The conclusion of the inquest was that she died as a consequence of her own actions though her intention is not clear beyond unreasonable doubt. The cause of death was 1a. Hanging. 4 CIRCUMSTANCES OF THE DEATH Helena suffered from bulimia and had been assaulted sexually whilst on a school exchange visit. This occurred during 2011 and the incident probably occurred in France. During October 2012 to January 2013 a number of events occurred including that she revealed the fact she was bulimic and the fact she had been assaulted, she took an overdose, self-harmed at a party, and wrote a number of letters which when read after her death appeared to have been suicide letters. Although she was referred by the School Nurse to Child and Adult Mental Health Services (CAMHS) she was not seen until the day before she died and no-one who saw her thought that she was suicidal and everyone who had dealings with her seems to have misunderstood her true feelings and intentions. CORONER’S CONCERNS 5 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. – (1) As for CAMHS (part of the Foundation Trust) the referral system was not working adequately and the referral was not followed up after triage even though it was classified as urgent. (2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers. 1 (3) Those dealing with Helena failed to recognise the escalation of the incidents in which she was involved in terms of their seriousness and their increasing frequency. (4) As far as Cumbria County Council is concerned, they are involved because I understand they are responsible for provision of the school nurse service although they contract this out to the Partnership Trust but nonetheless the responsibility lies with Cumbria County Council. I thought that the expectations of the school nurse in this particular case were totally unrealistic. I heard in evidence that she was responsible for 5 senior schools and 20 or more feeder schools to those 5 senior schools and although the total number of pupils involved was not clear, it is obviously thousands rather than hundreds. She worked a 26 hour week, had 40 current cases at Kirkbie Kendal School alone. The provision of service at this level is totally unfair on the school nurse concerned, unrealistic in the sense that others have expectations of a school nurse which one part time provider cannot meet. (5) The school’s counsellor had been in post for many years and there was no proof of her qualifications or her competence nor of update and training or registration with any professional body. The County Council needs to be more thorough with checking credentials. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I wish you to consider the matters set out above, to consider the Serious Untoward Incident Report compiled by the Foundation Trust, consider its recommendations and their implementation. I wish you to consider the Serious Case Review undertaken by the Safeguarding Children Board and its recommendations and to consider whether you should take action to implement those recommendations and I wish both organisations to contemplate the content and demeanour of those two reports and to consider whether in your respective roles, CAMHS and Cumbria County Council, can provide a safe environment for children to be dealt with because, sadly, this was not provided in relation to Helena. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1st September. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, and to the Local Safeguarding Board. I am 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, about the release or the publication of your response by the Chief Coroner. 2 9 [DATE] 3 July 2014 [SIGNED BY CORONER] Ian Smith 3
2 responses 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.
Cumbria County Council County Council Chief Execulive’s Office - The Couris - English Street Carlisle - Cumbria « CA3 8NA T: 9 September 2014 lan Smith HM Senior Coroner Central Police Station Market Street Barrow-in-Furness Cumbria LA14 2LE Dear fan Re: Regulation 28 Report — Helena Kathleen Farrell Thank you for your letter of 4 July regarding Helena Farrell. In responding to the Regulation 28 notice Cumbria County Council would like the following matters to be taken into consideration: 1. Cumbria County Council was not notified of or represented at the Inquest into the death of Helena Farrell. 2. No County Council employee was requested to provide a statement or report in relation to any matter considered at the Inquest. 3. Neither the County Council nor any of its employees were requested to attend the Inquest as an “interested person”. 4. Cumbria County Council has not had sight of the evidence presented at the Inquest (apart from that subsequently provided — the Serious Untoward Incident report, the Serious Case Review and the Coroner's summing up). Your recommendations for Cumbria County Council cover two broad areas: the commissioning of the School Nursing Service, and the checking of credentials of school counsellors. | shall respond to each in turn. 4. School Nursing Service. At the time of Helena’s death, the responsibility for commissioning the School Nursing Service lay with the then Cumbria Primary Care Trust. Cumbria County Council took over this responsibility on 1 April 2013 as a result of the national changes to the health service under the Health and Social Care Act 2012. At this time the existing school nursing contract with Cumbria Partnership Foundation Trust was extended until the end of September 2015 in order to give Cumbria County Council the necessary time to review and recommission the service as appropriate. Serving the people of Cumbria Swe Cy wvestors cumbria.gov.uk “MMS IN PEOPLE Cumbria County Council County Council In summary, while Cumbria County Council was not responsible for school nursing services at the time of Helena’s death, it is now. It is therefore clearly important that we learn any lessons arising from this case and build them into our planning for future services. Recognising the immediate pressure on the School Nursing Service, since April 2013 the Council has funded a further three posts within the service. However this has always been seen as a short term solution to relieve pressure while a more fundamental review of the service is undertaken. Your findings, together with the Cumbria Partnership Foundation Trust Serious Untoward Incident Report and the Serious Case Review Report, indicate a problem with capacity in the school nursing system meaning that school nurses are not able to devote the appropriate amount of time to cases that really need their input. We have therefore carried out a full case audit to determine whether the existing approach to safeguarding and child protection within the service could be improved. This audit has revealed a number of areas where the multiagency safeguarding system could be improved in order to reduce significantly the bureaucratic burden on school nursing, without increasing the risk to other children. This would clearly free up school nurse time to focus on other issues, including giving adequate time to individual cases where their input is most appropriate. We are working with the Local Safeguarding Children Board to amend the multiagency systems appropriately, and with Cumbria Partnership Foundation Trust to make the necessary changes within the School Nursing Service on a voluntary basis within the context of the existing contract. We will be building all necessary changes into the new service specification to be commissioned from October 2015. 2. School Counselling Services You recommend in your report that the Council “needs to be more thorough with checking credentials” of school based counsellors. The Council is not the employer of counsellors at Academies such as Kirkbie Kendal School or in Foundation or Voluntary Aided Schools. The Governing Body or the Academy appoints and employs all staff in these schools. The Council does employ counsellors at Community and Voluntary Controlled Schools however deciding which staff are appointed and ensuring the relevant employment checks are completed is the legal responsibility of the individual school. The school must adhere to relevant safeguarding guidance and employment law. The Council has in the past reminded schools of their duty to ensure that counsellors are appropriately qualified with appropriate clinical supervision. Following your report we shail do so again by the end of September and will also undertake a sample audit later in the school year to ascertain from schools whether they have complied with their duty. The results of this audit will be presented to the Local Safeguarding Children’s Board. Serving the people of Cumbria ee oy INVESTORS cumbria.gov.uk VW, w 3 IN PEOPLE Cumbria County Council County Council report. Yours sincerely Diane Wood Chief Executive gilt, ogi VA Serving the people of Cumbria See Cy investons cumbria.gov.uk Same ae IN PEOPLE | hope that the actions outlined above satisfactorily address the recommendations made in your
Cumbria Partnership NHS} NHS Foundation Trust : Voreda Learning Network and Trust HQ Portland Place PENRITH Tel No: nets Direct Line: Your ref: 2013-20/DP Our ref: SUI 2012 206702 01 September 2014 Private and Confidential — addressee only Mr | Smith LL.B HM Senior Coroner South and East Cumbria Central Police Station Market Street Barrow-in-Furness Cumbria LA14 2LE Dear Mr Smith The late Helena Farrell Inquest concluding 30 June 2014 Further to my previous letter of 17 July 2014, acknowledging receipt of the Regulation 28 letter, | have now considered the Matters of Concern and the actions the Trust is required to undertake. | detail below, the current Trust position and progress. In relation to: 1 The CAMHS (Child and Adolescent Mental Health Service) referral system The referral system has been significantly redesigned, as evidenced in the internal action plan at Appendix 1 (enclosed), points 5 and 6. The timescales for response to referrals deemed urgent is now 48 hours and any breaches are electronically flagged and investigated. Achievement of this demanding target has been consistently high. Page 1 of 3 Cumbria Partnership NHS) NHS Foundation Trust Pressures within all tiers of CAMHS (1-4) in Cumbria, with increasing numbers of young people presenting with more acute needs, is reflective of the National picture. Locally, agencies recognise that there are gaps in early intervention mental health and emotional resilience support for young people, across both statutory and voluntary sectors. This situation continues to put pressure on the Tier 3 service provided by CPFT. The Tier 3 service is still seen by some referrers as the ‘only option’ for young people under emotional pressure. This results in many inappropriate referrals to Tier 3 CAMHS and frustration for service users, who may face delays in accessing the limited alternative services which are available. : The Trust is working with commissioners and partners to develop Tier 2 preventative services and is currently contracting with qualified Third Sector providers to address increased waiting times in some areas. Additional work and education is underway with referrers to enable better understanding of the options for alternative care and intervention. 2 CAMHS staffing levels, skills and experience The Trust, with commissioners, has fully implemented the recommendations of the independent, external review of CAMHS in 2012 which has resulted in the staffing levels across the service increasing from 45 to 63, with improved skill mixes and clear development plans. Significant training has been identified, planned and delivery has commenced. Suicide prevention training was prioritised and delivered as shown in the action plan, point 10. Staff turnover is challenging in some areas, with a lack of skilled and trained staff available to fill the permanent positions available. The interim position of deployment of agency staff does not always provide the level of continuity of care required. 3 Recognition and action, following escalation of incidents This is covered within the training provided and re-enforced through the supervision processes in the action plan 4 The Serious and Untoward Incident (SUI) report Recommendations The recommendations contained in the action plan developed (Appendix 1) from the SUI Report, have been accepted and implemented in full. 5 The LSCB (Local Safeguarding Children’s Board) Serious Case Review The Trust has worked with the LSCB partners to develop the partnership response to the questions raised (Appendix 2) in the Serious Case Review and will play a full part in implementation. Lessons learned are integrated into the work of the Trust, especially within the Children and Families Care Group, Page 2 of 3 Cumbria Partnership NHS) . NHS Foundation Trust through their robust management and governance arrangements. These are supported by regular review and audit and external inspection. The Trust fully recognises that the programme of work is challenging and long term. The Trust regrets that the systems in place at the time of Helena Farrell’s referral were not sufficiently robust, but considerable work has been undertaken since, to strengthen arrangements, improve quality and review progress. These matters continue to receive significant internal scrutiny and the Trust is committed to ensuring that children and young people’s safety is the top priority, both now and in the future. This comprises the Trust's response to the Regulation 28 letter issued in relation to this matter. | hope that this is clear and of assistance. Please may | request that any further correspondence on this matter is sent to Dr Sara Munro, Director of Quality and Nursing in the first instance. Dr Munro’s contact details are set out above. Yours sincerely Mrs Claire Molloy Chief Executive lace Page 3 of 3
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