Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0347, written 28 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 | 28 Jul 2014 |
|---|---|
| Reference | 2014-0347 |
| Deceased | Frances Andrade |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | Other related deaths |
| Organisation named | Surrey and Borders Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquests Touching the Death of Frances Claire ANDRADE A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: 1. The Director of Public Prosecutions in relation to paragraphs 5(1) & (2). 2. The Chief Executive of the Surrey and Borders Partnership NHS Foundation Trust in relation to paragraph 5(3). 1 CORONER Richard Travers HM Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST The inquest into Mrs Andrade’s death was opened on the 13th January 2013 and was resumed on 7th July 2014. It was concluded on 25th July 2014. The cause of death was: 1a – An acute overdose of fluoxetine and insulin. The conclusion was: Francis Claire Andrade died from an overdose of fluoxetine and insulin but her intention for taking that overdose was unclear. 4 CIRCUMSTANCES OF THE DEATH In the summer of 2011 a friend and colleague of Mrs Andrade made a report to the police alleging that Mrs Andrade had been sexually abused as a child and more particularly as a young teenager whilst attending the Cheethams School of Music in Manchester. Mrs Andrade had not agreed to the report being made and, therefore, found herself in a position that was not of her own making. She was interviewed by the police in July 2011 and again in December 2011. From about the date of the first interview she required anti‐depressant medication. Prior to that event, she had not required such medication. In April 2012 she took the first of a number of overdoses. This coincided RT4173 1 with the date at which the allegations and the fact that the matter was to go to trail first appeared in the national press. Evidence was given by a number of witnesses that Mrs Andrade had reported that she had been told by the police that she should not be receiving counselling or psychiatric support as it might adversely affect her evidence at trial. That assertion was not supported by any direct evidence. Rather, there was evidence that an officer from the Greater Manchester Police had put her in touch with RASASC (a local support charity for those who have suffered sexual abuse and rape). Nevertheless, it was apparent that as far as Mrs Andrade was concerned, this issue was a cause of uncertainty and anxiety. agave evidence that in the twelve month period prior to the trial his wife’s character / demeanour changed dramatically; on his account she became very introverted and depressed. There followed a number of further overdoses which became increasingly more serious as the date of the trial (January 2013) approached. An assessment in late October 2012 by an Occupational Therapist from the Guildford Community Mental Health Recovery Service (‘GCMHRS’) was followed by a multi‐disciplinary team meeting on the 5th November 2012 at which Mrs Andrade was put forward for a care coordinator which, significantly, she agreed to and she was zoned ‘red’ (urgent). The zoning was recorded incorrectly as ‘amber’, but despite the fact that that mistake was recognised in the first half of December 2012, the fact that there was a serious intervening overdose (14th December 2012) and the fact that a psychiatric assessment (19th December 2012), noted that she had been referred for urgent care coordination, Mrs Andrade was not allocated a care coordinator until the 2nd January 2013 and then the person who was allocated to her was off sick with no known date for his return. By the time of her death on 24th January 2013 a care coordinator had still not been allocated. Mrs Andrade gave evidence at the trail in Manchester on the 14th and 15th January 2013. On the day before she died, the learned trial judge, in response to submissions from counsel, directed that not guilty verdicts should be entered on various counts on the indictment. Those submissions were based upon issues of law that did not relate to the credibility or reliability of Mrs Andrade’s evidence. The not guilty verdicts were reported in the media, but no explanation in this regard was given to Mrs Andrade. She was found in her bed by her husband the following morning; there were no signs of life and death was confirmed by the paramedics on their attendance a short while later. She was found to have taken an overdose of both fluoxetine and insulin. The insulin which she had used was prescribed to her husband and had RT4173 2 been kept in the fridge at the family home. Despite the fact that this was the fourth overdose in which she had used her husband’s prescribed medication (insulin) no real or effective steps had been taken by those charged with providing psychiatric care to Mrs Andrade to secure that medication with a view to restricting her access to it. Evidence from the new service Manager at the GCMHRS set out in detail changes which had been instigated in the Service since Mrs Andrade’s death. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters that gave rise to concerns that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken. The MATTERS OF CONCERN are as follows. – 1. Consideration should be given to instituting measures that will ensure that clear and unequivocal advice is given to a vulnerable witness in relation to the obtaining of psychiatric counselling in relation to issues arising from evidence which they will be giving in forthcoming criminal proceedings. 2. Consideration should be given to instituting measures that will ensure that complainants in criminal trials are given a full and timely explanation as to the directions given by a trial judge in relation to counts on an indictment following the receipt of submissions of there being no case to answer in respect of those counts. 3. Where there is a history of overdoses being taken by family member A using medication that is prescribed to family member B, consideration should be given to what steps could reasonably be taken to secure that medication with a view to restricting access to it by family member A. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the Director of Public Prosecutions and the Chief Executive of the SABP NHS Foundation Trust have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. RT4173 3 Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the following Interested Persons in the Inquest and to the Chief Coroner. 1. 2. The Greater Manchester Police 3. The Surrey Police 4. CPS Northwest 5. SABP NHS Foundation Trust 6. 9 Signed: Richard Travers DATED this 28th day of July 2014 RT4173 4
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.
Surrey and Borders Partnership NHS) NHS Foundation Trust Trust Headquarters Private & Confidential 18 Mole Business Park HM Coroner for Surrey Leatherhead HM Coroner's Court Surrey KT22 7AD Station Approach Surrey Fax: GU22 7AP Friday, 19 September 2014 Dear Mr Travers, Inquest into the death of Francis Andrade - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Further to the conclusion of the inquest into Mrs Andrade’s death on 25" July 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern. We would like to take this opportunity to continue to offer our sincere condolences to the Andrade family for their loss. The area of concern you raised that relates to our Trust and our response are deiailed below: Where there is a history of overdoses being taken by family member A_using medication that is prescribed to family member B, consideration should be given to what steps could reasonably be taken to secure that medication with a view to restricting access to it by family member A. Due to the limited influence we have on how members of the public store or manage their medication it will, unfortunately, be unrealistic for us to say we can fully mitigate against this risk going forward. We have however taken steps to ensure that our staff interactions with family carers and people using services recognise this risk and highlight it as an area to be considered by all parties involved. Further to our own internal investigation we have since recommended that staff should ensure that when specific risks are identified in a person [e.g. a person is assessed to be hoarding medication and using other person's prescribed medication to overdose], this must be followed by comprehensive risk management care plan/s in collaboration with the person/s and shared with the Team directly involved in the person's care. We believe that a process managed through effective care planning arrangements with clear engagement with the person using our service and the carer, would be the most effective process that may go some way to mitigate this risk. For a better life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD T_0300 55 55 222 F_01372 217111 www.sabp.nhs.uk We monitor compliance with care planning through our Board Key Performance Indicators to ensure that the process of care planning remains embedded. Our Home Treatment Team has developed a local protocol to ensure safety of medication management and further to the investigation they are expected to establish a safety plan with the person and family for the safe storage of medication if a history of overdosing on family’s medication has been revealed. Further to the outcome of the inquest, we will be holding a workshop as part of our Suicide Prevention Action Group process to share the learning to a wider group of Clinical staff to ensure embedding of the learning. Our Board has been made aware of your letter and we would like to once again offer our sincere condolences to the Andrade family for their loss and hope that the steps we have taken as outlined above assures you and them, that we have learnt and continue to learn from Mrs Andrade’s death. Please do not hesitate to contact me or HE Director of Quality (DoN) if you require any further information. Yours sincerely hief Executive — Director of Quality (DON) Medical Director GE Director of Risk & Safety (DDoN) Ee — Director of Mental Health Cc
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