Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0574, written 16 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 | 16 Dec 2014 |
|---|---|
| Reference | 2014-0574 |
| Deceased | Janette Insley |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Mental Health related deaths |
| Organisation named | Pennine Care NHS Foundation Trust |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Health, Department of Health, London CORONER 1am Ms L J Hashmi, Area Coroner for the Coroner area of Manchester North. CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 5" December 2014, | commenced an investigation into the death of Ms Janette Insley. |... CIRCUMSTANCES OF DEATH The Deceased had a longstanding history of depressive illness. In May 2014 her mental and psychological health deteriorated markedly resulting in her admission to a mental health unit as an informal patient. She declined pharmaceutical intervention on the basis that she believed she was suffering from Protracted Withdrawal Syndrome and that medication was responsible for her signs and symptoms. The doctors caring for the deceased did not share this view, their diagnosis being that the deceased was suffering from traits of personality disorder and an inability to cope with psychosocial stressors. They felt that there was no evidence of a biological depressive disorder during the course of the index admission. Upon this basis, the hospital doctors considered that referral to a Psychologist for care and treatment was the most appropriate course of action. Discharge planning was commenced and halted on several occasions due to episodes of serious self-harm by the deceased, including attempts at self-ligature and overdose. During the course of her inpatient stay, the deceased was allowed time off the ward/leave away from the ward, subject to risk assessment by care staff. On the whole, whilst very stressful for the deceased, the periods of leave passed without incident. However, on the 3 August 2014 the Deceased failed to return to the ward following afternoon home leave. Enquiries were made by ward staff and the deceased's ex-partner/friend in an attempt to make contact. Ms Insley was subsequently found deceased at her home address later that evening, having self- ligatured. 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 fo you. The MATTERS OF CONCERN are as follows:- 1. During the course of the evidence | was told that whilst the Consultant Psychiatrist considered that a referral to a Psychologist was the most appropriate course of treatment available, staff were unable to make any such referral for inpatients due to lack of i) availability of suitably qualified practitioners and ii) resources. There is therefore a clear service gap. : 2. | was also told that most, if not all, Psychological therapy now takes place within the community. It would appear that undue emphasis is currently being placed upon this setting of care, to the detriment of inpatient services. 3. That any referral to/consultation with a Psychologist based within the community would have taken at least 3-4 weeks post-discharge, thus leaving the patient without therapy during a particularly vulnerable period. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively 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 11" February 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 namely:- - The Deceased’s family - Pennine Care NHS Trust - CEO, Bury CCG ! 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 from. 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: 16" December 2014 Signed: GL ™ -
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.
AS AER Z From Norman Lamb MP Minister of State for Care and Support Department of Health Richmond House 79 Whitehall London . SWI1A 2NS Mrs L Hashmi Tel: 020 7210 4850 Area Coroner HM Coroner’s Court The Phoenix Centre L/Cpl Stephen Shaw 27 FEB 2015 MC Way Heywood OL10 1LR Dew (Ln Habhhnr, I Thank you for your letter following the inquest into the death of Janette Insley. I was very sorry to hear of Ms Insley’s death and wish to extend my sincere condolences to her family. The inquest concluded that Ms Insley died as a result of self-ligature. I understand Ms Insley had a history of depressive illness and in May 2014 was admitted as an informal patient to a mental health unit. Her doctors believed she had a personality disorder and considered that referral to a psychologist for care and treatment was the most appropriate action. Although discharge planning then commenced it had to be halted several times due to serious self-harm episodes by Ms Insley. During her inpatient stay, Ms Insley was allowed leave away from the ward, subject to risk assessment by staff. On the whole, these periods of leave passed without incident. Unfortunately on 3 August 2014 she failed to return from an afternoon home leave and was discovered dead at her home address later that evening. You have a number of concerns following the inquest: e Although the consultant psychiatrist considered that a referral to a psychologist was the most appropriate course of treatment available, staff were unable to make any such referral for inpatients due to lack of i) availability of suitably qualified practitioners and ii) resources. You consider there is therefore a clear service gap; e You were told that most, if not all, psychological therapy now takes place within the community. You consider that undue emphasis is currently being placed upon this setting of care, to the detriment of inpatient services. e You note that referral to/consultation with a psychologist based within the community would have taken at least 3-4 weeks post-discharge, thus leaving the patient without therapy during a particularly vulnerable period. You have copied your report to the relevant NHS Trust and Clinical Commissioning Group. The issues you raised are most appropriately addressed at a local level and I would expect the NHS organisations responsible to respond fully to your concerns. At a national level the Government is investing over £400 million over the current spending review period to enable a greater choice of psychological therapies to be offered to patients who need them, across the whole of England. The Department of Health’s 2014-15 Mandate to NHS England makes clear that “everyone who needs it should have timely access to evidence based services”. The Mandate sets a clear objective for NHS England to deliver the key objectives of the Improving Access to Psychological Therapies (IAPT) programme. This includes providing access to therapies to 15% of those eligible (around 900,000 people per year), per year by 2015, with a recovery rate of 50%. The Outcomes Framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the JAPT programme. In addition, the Department’s new five-year plan for mental health, Achieving Better Access to Mental Health Services by 2020 was published in October 2014. This articulates our ambition and the immediate actions we will take this year and next to achieve better access and waiting times in mental health services. This includes the IAPT commitment of treatment within 6 weeks for 75% of people with 95% of people being treated within 18 weeks. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Ms Insley’s death to my attention. L A-ce-cA_, ‘ PL _..| 2 NORMAN LAMB
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