Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0535, written 17 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2014 |
|---|---|
| Reference | 2014-0535 |
| Deceased | Rebecca Overy |
| Coroner | Stephanie Haskey |
| Coroner area | Nottinghamshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
From Norman Lamb MP Minister of State for Care and Support Department of Health Richmond House 79 Whitehall London ; SWIA 2NS Miss S Haskey Tel: 020 7210 4850 Assistant Coroner Coroner’s Office The Council House Old Market Square Nottingham 27 FEB 2015 NGI 2DT Thank you for your letter following the inquest into the death of Rebecca Overy. I was very sorry to hear of Miss Overy’s death and wish to extend my sincere condolences to her family. The inquest concluded that Miss Overy died of a hypoxic brain injury as a result of asphyxia whilst a patient in adult secure mental health detention. Her fatal injury was self- inflicted. Miss Overy had been transferred from a secure child and adolescent mental health unit to an adult secure mental health unit the day after her 18" birthday. No plans had been made for a gradual transition to the adult facility nor had she visited the adult institution before her transfer. This case highlights issues about the transfer of adolescents into adult mental health units and the provision of secure mental health for young people aged 18 to 24. You raise the following concerns for our attention : e The immediate transfer of Rebecca the day after her 1 8" birthday was not in her best interests, it was detrimental to her mental health and occurred due to the operation of a 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer, and the clinicians to concur with it, lest they be in breach of the Act. © There is no provision for secure mental health care for young adults aged 18 — 24, with a clinical picture similar to Rebecca’s. I have obtained information from NHS England about this case. I understand that Miss Overy’s death was the subject of a serious case review, for which NHS England provided a detailed report. Your first concern is about the age of transition from CAMHS. The Government is aware that there is wide variation in NHS practice when children and young people move from a Child and Adolescent Mental Health Service (CAMHS) ward or elsewhere. Different services choose to transition at different ages: 16, 18 or older. A person aged 18 is legally an adult. An adult patient on a CAMHS ward could lead to child protection and adult safeguarding issues. For this reason, some services currently choose to move a patient to an adult ward at age 18, with the move taking place on the 18" birthday or the day after. However, it is the Government’s clear aim that transition between services should not focus on age, but on the needs of the individual. Transition between services should always be based upon the needs of the individual, and subject to professional clinical judgement. Transition requires careful planning and we want to see a whole system approach in which the child or young person is supported along the care pathway according to needs. The key to successful transition planning and actual transition arrangements is that the CAMHS provider is supportive of plans by local clinicians and teams, working as part of that team in the transition process. Likewise the provider of adult services must anticipate and meet the additional needs for a young adult in the service. Improving transition and ending the ‘cliff edge’ of support many children and young people face as they reach 18 is a key commitment and priority for action in Closing the Gap: Priorities for essential change in mental health, launched by the Deputy Prime Minister and me on 20 January 2014. In support of this, in December 2014 and January 2015, NHS England published new service specifications for commissioners, giving guidance and best practice on transition from CAMHS. These fulfil a major objective for this priority. These specifications intentionally do not stipulate an age threshold for transition but state transition should be built around the needs of the individual, not focussed on age’. This is part of the Government’s commitment to parity of esteem between mental and physical health services. In addition, I commissioned the Children and Young People’s Mental Health and Wellbeing Taskforce in August 2014 to improve the way children and young people’s mental health services are organised, commissioned and provided to make it easier for young people to access help and support. Transition is one of the key issues I have asked the Taskforce to address. ' Available at http://www.england.nhs.uk/resources/resources-for-ccgs/#camhs-tools ab Department of Health The Taskforce has sought the views of young people, their families and carers as well as those working with children and young people. A report will be published in the Spring. You refer to the “operation of a section 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer”. | am not aware of a provision from either the Health and Social Care Act or the Mental Health Act which stipulates this, so am unable to comment on this specific matter. However, if you are able to provide clarification for this reference I am happy to respond further on this point. NHS England have assured me that Miss Overy’s future care had been considered for many months prior to her transfer including the appropriate type of environment and level of security required. They have confirmed that an independent clinical access assessment had been undertaken that identified that Miss Overy should be in an adult low secure placement when she turned 18. The CAMHS placement where she was, was not of a low secure environmental or therapeutic standard that would meet her identified needs. In addition, Miss Overy’s significant levels of risk and patterns of behaviour meant that she would not have been able either to remain within a CAMHS or be discharged to the community when she became an adult. I would expect providers of adult secure mental health services to act in accordance with the Mental Health Act 1983 Code of Practice to ensure that the needs of the patient are identified on admission to an adult secure hospital and an individual care plan for meeting these needs is put in place. I would also expect patients, families and carers to be involved in decisions to admit to a secure hospital. The Code of Practice identifies a number of factors for consideration in making this decision, including the wishes and views of patients, their ages and physical health, cultural backgrounds and their social and family circumstances. However, the safety of the person and others is an important consideration in making this decision and should be guided by an assessment of risk including suicide, self-harm, self-neglect and jeopardising health and safety accidentally or intentionally. Assessments of patients should also be made to understand their needs and identify potential risks. Individual care plans should be put in place to meet patients’ needs and manage risks in a therapeutic way within the least restrictive environment. Where there is a risk of disturbed behaviour such as self-harm or risk of suicide, the Code of Practice identifies a number of factors to be considered such as the impact of the physical and therapeutic environment, emotional distress and the mix of patients within the secure ward or unit. The Department of Health is currently revising the Code of Practice, which will come into effect from 1 April. The Department has worked with partners, expert bodies and an extensive range of stakeholders including mental health professionals, carers, advocates and service users to strengthen the Code of Practice in key areas. The revised Code of Practice will include a strengthened section on meeting the needs of patients upon admission to hospital and brings to the fore the need to involve patients, their carers/advocates and families in decisions about care. The revised Code of Practice will make clear that providers should have policies and guidance in place for conducting individualised assessments which are based around the needs of the patient. However, it will go further by highlighting that strategies should be developed to enhance quality of life and prevent disturbed behaviour through individualised behaviour support plans, which patients, carers/advocates and families should be fully involved in developing. You were concerned that there is no provision for secure mental health care for young adults aged 18 — 24 with a similar clinical picture. Whilst there are no dedicated wards for 18 to 24 year olds, there are wards that meet the clinical needs of patients with the same and similar presentation to Miss Overy. There is transition guidance in place which advises that arrangements are made within adult wards to ensure that appropriate patient needs, as highlighted in clinical assessments, are met. Receiving providers should make appropriate plans and extend the services available to aid the transition arrangements for young adults. One such example of this is a ‘Buddy System’. J understand that in this case, Partnerships in Care, who were the provider of the adult mental health services that Miss Overy received, had established a Buddy System for Miss Overy with another young person, who was already on that ward and aged 18. Relevant transition guidance can be found in the Access Assessment Commissioning Guidance May 2012 for secure services (copy enclosed with this reply). This guidance provides commissioners of secure mental health services with direction on how best to ensure high quality outcomes for the assessment of need. The assessment determines if a referred patient requires care under conditions of security and, if so, at what level. Department of Health An Access Assessment is the clinical assessment of the mental health and risk- management needs of an individual. This assessment determines the most appropriate placement for the individual in terms of need and level of security, with consideration of the whole care pathway. The guidance contains an expected outcome for the transition from Adolescent Services to Adult Secure Services. There should be a managed pathway between adolescent mental health services and adult secure services. Best practice guidance is also highlighted within the Children’s and Families’ Services Guide 44 — Mental health service transitions for young people from the Social Care Institute for Excellence (SCIE) which can be found at www.scie.org.uk/publications/guides/guide44/files/guide44.pdf I hope that this response is helpful and I am grateful to you for bringing the circumstances of Miss Overy’s death to my attention. La pane” ae a OU Ne we NORMAN LAMB ae
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 JS BEING SENT TO: 1. The Department of Health 1 | CORONER lam Miss Stephanie Haskey, Assistant Coroner, for the Coroner area of Nottinghamshire 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 From 17" to 27th November2014 the death of Rebecca Louise Overy was the subject of an Article 2 Inquest. It was found that Miss Overy had died as a result of hypoxic brain injury as a result of asphyxia whilst in adult secure mental health detention, The jury returned a Narrative Conclusion. 4 | CIRCUMSTANCES OF THE DEATH Miss Overy’s fatal injury was self- inflicted, and occurred whist she remained on the'adult admission ward. She had been transferred there from Child and Adolescent secure mental health detention the day after her 18" birthday, without any prior visit to the adult intuition and without any plan for a gradual transition, given Miss Overy’s particular circumstances, despite this being proposed by her adolescent responsible clinician. 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: 1.That the immediate transfer of Miss Overy the day after her 18" birthday was not in her best interests, was detrimental to her mental health and occurred purely due to the operation of s 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer, and the clinicians to concur with it, lest they be in breach of the act. 2. That there is no provision for secure mental health care for young adults in the age range 18-24, with a clinical picture similar to Rebecca's. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 1S -Z- (Ss: 1, 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: | have also sent it to: WDA ABW N= (mother) (father) 8 9 1 1 1 1 ! 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] yy [SIGNED BY CORONERF W/ . - hani k [7 - C2 gy Stephanie Haskey tte
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