Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0486, written 11 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Nov 2014 |
|---|---|
| Reference | 2014-0486 |
| Deceased | Rowena Golton |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Manchester Clinical Commissioning Group Parkway 3 Parkway Business Centre Princess Road Manchester M14 7LU Manchester Mental Health and Social Care Trust 1 | CORONER | am Joanne Kearsley, Area Coroner, for the coroner area of South Manchester 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 the 10" April 2014 | commenced an investigation into the death of Rowena Kathryn Golton, date of birth 26.02.1969. The investigation concluded on the 15" August 2014 and the conclusion was one that the deceased had taken her own life. The medical cause of death was 1a) Multiple Traumatic Injuries. 4 | CIRCUMSTANCES OF THE DEATH The deceased had a history of recurring depression which became more pronounced from August 2013 onwards. She had attended at her GP surgery initially and then in January 2014 had seen the mental health services. A recurring feature throughout her presentation was suicidal thinking. The deceased had a period of inpatient admission and subsequent involvement of the crisis team. There was clear evidence that the deceased needed longer-term psychological therapy. A referral had been made but due to the length of the waiting list she had not been seen. On the 6" of April 2014 the deceased jumped from the fire escape at the top of Vernon Mill in Stockport. At the time of her death she was suffering from deterioration in her mental illness. In the early hours of the 6" of April the deceased had presented at the A&E Department at Manchester Royal Infirmary having been brought back from abroad by her mother who had travelled to collect her following her admission to hospital in Morocco as a result of her mental illness. She was assessed as a low risk of suicide and discharged with a plan for her to be seen later in the day on the 6" of April by the crisis team. 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. — - Evidence was given as to the lack of availability of psychological services within the crisis teams. Following her admission as an inpatient she was then under the care of the crisis team. Not all crisis teams have access to a psychologist and the internal investigation recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access. - In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 6 January 2015. |, 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 | 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. Date: 11 November 2014 Joanne Kearsley, HM Area Coroner Manchester South
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.
NHS North, Central and South Manchester Clinical Commissioning Groups Citywide Commissioning, Quality & Safeguarding Parkway 1 Parkway Business Centre Princess Road Manchester Tel. Safe Haven Fax: 22"* January 2015 RECEIVED 26 JAN 2015 Dear Ms Kearsley Re: Rowena Kathryn Golton (Deceased) Further to your letter dated 5‘ January 2015 | would like to provide a response to your points raised. We have not, as yet, received any information from Manchester Mental Health and Social Care Trust in relation to the lack of availability of psychological therapies in crisis teams. ME Head of Mental Health Improvement Programme, is working closely with Trust colleagues to review service provision across all services and to develop care pathways for service users. With regards to Manchester Mental Health and Social Care Trust response indicating that they have reviewed access to clinical psychology services | can confirm that the Citywide Team commissioned a review of psychological therapies (IAPT) with the two providers of this service in Manchester; Manchester Mental Health and Social Care Trust being one of the providers reviewed. | assume that this review is what the Trust response relates to as |! am not aware of any separate review of [APT being undertaken. The National IAPT Intensive Support Team was asked to undertake a diagnostic review of the Citywide IAPT services. The review was requested by Commissioners in response to our low performance for the national indictors and the need to achieve 15% access to psychological therapies in line with the IAPT programme and the long waiting lists. An external and expert review was required to help understand why performance is low. The subsequent report offered a number of options to consider to more effectively offer NICE recommended therapies for mild to moderate-severe anxiety and depression, Step 2 and Step 3 psychological therapies (IAPT). As a result both commissioners and providers are working together to implement the recommendations of the report. We aim to increase access to psychological therapies by increasing productivity of services currently commissioned and to align other commissioned services to this pathway of care. With regards to the waiting time for access to psychological therapies information supplied in your letter by Manchester Mental Health and Social Care Trust | would like make the following comments. The information in your letter details the activity levels for Clinical Psychology and Psychotherapy Service in relation to step 4 psychological therapies. This information was sent to me in a letter by FY (Director of Operations, MMHSCT) on the 23” December 2014. In her lette ij proposed the closure of the waiting list for complex cases from the 1* February 2015 until the 18 week referral to treatment pathway can be delivered by the Trust. | was unable to support this proposal due to patient safety risks. Following the National IAPT team review and the examination of the Psychological Therapies CQUIN that is in place relating to waiting times, Commissioners now have a better understanding of how the Trust manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are being taken by the Trust to regularly cleanse and review the number of patients waiting. We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data. The Trust have indicated areas of significant pressure and that complex cases service are exceeding ‘the available commissioned resource’. Within the block contract in place there is no specific allocation for this service or any other Psychological Therapies, with the exception of IAPT, and so | am unsure what the Trust considers ‘the available commissioned resource’ is. We have recently made a request to (Director of Finance) at the Contracts Meeting with the Trust for information regarding the level of Psychological Therapy input into inpatient and community services to understand which services have input and which do not. As commissioners we do not have access to this information and although some existing service specifications detail psychological therapy input it has become evident that some services do not have the access we believed was available and we need a clear picture across the Trust services. We have also asked for clarification from the Trust as to why they have identified Psychological Therapies within its Cost Improvement Programme (CIP) plan when there are such long waiting lists. For the past few years the Trust has identified a significant contribution toward its CIP plan from vacancies within the Psychological Therapy service budget and the letter from the Trust indicated that ‘without additional investment the service does not have sufficient commissioned resource to address its historical waiting list and provide timely access to newly referred clients’. | have made it clear to Manchester Mental Health and Social Care Trust that | do not support Psychological Therapies being included within CIP plan whilst extensive waiting lists exist. | have asked for a meeting to be arranged with The Trust, once we have received additional information we have requested, so that we can have a more informed discussions regarding the next steps in addressing the issues identified. ! hope this addresses your concerns, please do not hesitate to contact me if you require more information. Yours sincerely Executive Nurse and Director of Citywide Commissioning, Quality and Safeguarding
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