Amanda Hawkins

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oT REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

4. Mr P Sims, Chief Constable, West Midlands Police

| lam Mrs Margaret Joy Jones assistant coroner for the coroner area of Staffordshire

CORONER |

South

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 28 July 2014 | commenced an investigation into the death of Amanda Hawkins,
44 years of age. The investigation concluded at the end of the inquest on 25

November 2014. The conclusion of the inquest was la Unascertained with an open
verdict.

| care and a change of care co-ordinator. In June 2013 she transferred to 17 Moxley
| Court Wednesbury West Midlands, where she was free to come and go as she

CIRCUMSTANCES OF THE DEATH

The deceased was 44 years of age and had a long standing diagnosis of
schizophrenia. Due to closure of rehabilitation placements she had been obliged to
move three times over three years each time resulting in a step-down in her level of

chose. Her history did not indicate any risk of suicide or self-harm but she did have
a history of returning late to the accommodation and had done so on the 22nd May
2014. She was last seen at her accommodation at 09.00 hours on the 30th May
2014 and was reported missing by her mother at 21.51 hours on the 30th May 2014
to West Midlands Police. An ongoing search was failed to find her and her naked
decomposed body was found by passers-by at 1820 hours on the 22nd July 2014 in
a copse adjacent to a disused railway line off Meerash Lane Hammerwich close to
where she had last been seen getting off a bus. Post mortem and toxicology
examination found signs suggestive of hypothermia, quetiapine in the liver of

uncertain significance and no obvious signs of trauma. The cause of death was
unascertained.

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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. —

en cee cn — seen

(1) When Amanda was reported missing she was classified as medium risk. No
contact was made with her healthcare professionals. Had such contact been made
earlier in the enquiry her risk profile may well have changed to high risk at an earlier
point. This in turn may have led to a different approach in the search for her.

[

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ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and |
your organisation have the power to take such action. i

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 21 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
Persons: the family of Amanda Hawkins. |

| 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.

xe)

26 November 2014
Margaret Joy Jones
Assistant Coroner
Staffordshire (South)

Dudley and Walsall Mental Health Partnership NHS Trust 
Trafalgar House, 
47 – 49 King Street, 
Dudley, 
West Midlands, 
DY2 8PS 

Margaret J Jones (Assistant Coroner) 
Coroner’s Office 
No 1 Staffordshire Place  
Stafford 
ST16 2LP 

RE: Amanda Hawkins Deceased 
Ref: 

Thank you for your letter dated 26th November 2014 following the inquest into the death of Amanda 
Hawkins.   

The Trust has taken the opportunity to carefully review the Regulation 28 report issued following 
the conclusion of the inquest into Miss Hawkins’ death and, as an organisation; we are now in 
position to provide a full response. 

Firstly we would like to reiterate our very sincere condolences to Miss Hawkins’ family.  The death 
of someone close is always hard to bear, even more so in such tragic circumstances and as a 
Trust we are extremely sorry for the distress that the Hawkins family must be experiencing.   We 
would like to reassure you that upon hearing of Miss Hawkins’ death, the Trust launched an 
immediate and thorough incident investigation which looked at all of the relevant events leading up 
to this tragic event.  The purpose of this investigation was to help us to review the services 
provided and establish if there were any lessons to be learned as a result. 

In addition to this investigation, the organisation also conducted an investigation (in line with the 
Trust’s Complaints Management Policy) after it was initially reported that Miss Hawkins had gone 
missing.   

If you would find it helpful, the Trust would be happy to provide you with a copy of the completed 
investigations once they have been finalised. 

First concern 

Within your letter dated the 26th November 2014 you raise 2 points of concern.  The first of these is 
that: 

“The moves following closure of various homes or changes in funding and step down in services 
offered to Amanda resulted in her increased vulnerability”.   

As part of the requirements of Miss Hawkin’s care package, she resided at a number of different 
placements since the need for a supported placement first arose after her admission to St 
Matthews Hospital, Burntwood in 1990.  Her longest duration supported placement commenced in 
November 1991, whereby she resided at Pinfold House, Darlaston until the closure of this facility in 
2009.  As a result Miss Hawkins was transferred to Oak House, Walsall a supportive living 
placement provided by Caldmore Housing, where she remained until this residential home was 
also closed in October 2011.  In response to the closure of Oak House, Miss Hawkins’ placement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 was transferred to Lonsdale House where she remained until her care was transferred to Moxley 
Court in 2013. 

The investigation/review highlighted that at the time of her placement it was appropriate for Miss 
Hawkins to reside at Moxley Court as it was felt that the step down in placement was clinically 
appropriate for Miss Hawkins. She had previously had a consistent care team (from CRS South) 
with who she generally engaged well with.  The clinical appropriateness of this step down is further 
supported by the fact that Miss Hawkins was assessed as being able to maintain her own safety in 
the community without the need for further assistance in this regard.  

Our staff undertake individualised risk management in respect of each individual patient. This 
requires a fine balance between maintaining patient safety, whilst at the same time gaining the 
patient’s trust to build up therapeutic relationships and independence so that their care can be 
managed in the least restrictive setting. We have to manage this balance between care and control 
carefully and it is fundamental to our practice that we can continue to make individualised 
judgement calls for each and every patient as part of the clinical decision making process. 

Miss Hawkins was being seen at least twice per day by staff at Moxley Court and having 10 hours 
of dedicated time per week from the staff based at the placement.  It was known that Miss Hawkins 
had a long history of leaving the placements that she resided in and there had been occasions 
where she had failed to return to her placement, as agreed, at Pinfold House, Oak House and 
Lonsdale House.  At the time of her disappearance from Moxley Court, Miss Hawkins, her family 
and her care co-ordinator had a consistent plan in place of how to manage occasions when AH 
failed to return to her placement in the evening. 

It is the Trust’s view that in cases where there is a history of patients spending a prolonged time 
out of the placement they reside in, it will be the responsibility of the panel responsible for the 
allocated funded package of care to develop a risk assessment.  The risk assessment would aim to 
identify how the risk of the patient not returning to the placement could be mitigated and identify 
what further support can be provided to the patient to enable effective engagement with the 
community services in a safer and more supportive manner. 

The investigation / review recommended that where step down to 24 hour care provision is being 
managed through the panel process, utilising placement providers to manage an increase in 
independent living, the care plan should: 

1. 
2. 
3. 

Identify the rational for a change in care provision; 
Identify the amount of clinical time required to support the patient effectively; 
Identify the time allocation and level of input being provided by the placement provider; and 
identify the time allocation and level of input being provided by staff representing the Trust. 

The investigation process also identified that consideration should be given as to whether it is 
appropriate for the transfer of care to a new team to take place when patients move placements, or 
whether responsibility should remain with the existing team (for an initial period of time at least). 

Second concern 

In respect to your second point of concern: 

“That Hospital appointments were sent to Amanda at her home address when she did not have 
sufficient understanding to deal with correspondence and that care co-ordination workers were not 
made aware of missed appointments and that there was therefore no follow up and that the lack of 
follow up led to her increased vulnerability”.   

As part of the Trust’s investigation into the circumstances around the death of Miss Hawkins, the 
issue of missed appointments and the associated follow up was looked at in some detail.  The 
Trust concedes that Miss Hawkins was known not to respond effectively to correspondence and 

 
 
 
 
 
 
 
 
 
 
 
 did not always keep outpatient appointments, however, in the main she generally engaged well 
with services, although at times she did not attend appointments.  This was particularly evident 
with regards her outpatient appointments following her transfer to the North Sector CRS, with Miss 
Hawkins failing to attend appointments on 11th September 2013, 13th November 2013, 19th 
February 2014 and 21st May 2014. 

The Trust utilises the Oasis electronic system which logs and records appointments and instances 
when patients fail to attend.  The Trust does however acknowledge that letters from North 
Community Recovery Service (CRS) medical teams were not copied to the care coordinator or 
placement provider for them to be aware of the appointments that Miss Hawkins did not attend and 
therefore no subsequent follow up was made.  This is acknowledged as an area of improvement 
for the Trust which will be managed through the Trust’s embedding lessons processes.  Therefore, 
going forward within CRS North outpatient letters are now copied to the care coordinator and in 
addition to this, the Trust has convened a Working Group to look at long term solutions to this 
issue; this Working Group is being led by the Trusts Head of Recovery Services. 

Where appropriate, consideration will also be given to copies of such letters being sent to 
placement providers, however this would need to be done in line with existing policies regarding 
consent and the sharing of information. 

Furthermore where patients receive care as part of a placement, the care plans for such patients 
should indicate how the patient will attend outpatient appointments and whether anyone needs to 
attend with them and who this will be.  It is the aim of these two changes to ensure that all care 
professionals are aware of non-attendance of appointments and that this will ensure that there is 
effective follow up. 

If you require any further information in respect to the case or should the family of Miss Hawkins 
require any further information or support in respect to the investigation into Miss Hawkins death 
please do not hesitate to contact the Trusts Clinical Governance Department on 01384 65200 

I hope that this response adequately addresses the matters of concern raised in your letter and 
please do let me know if I can be of any further assistance. 

Yours Sincerely  

Gary Graham 
Chief Executive Officer