Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0013, written 16 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jan 2015 |
|---|---|
| Reference | 2015-0013 |
| Deceased | Louise Henry |
| Coroner | Sophie Cartwright |
| Coroner area | Derby & Derbyshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 THIS REPORT IS BEING SENT TO: 1. Derbyshire Healthcare NHS Foundation Trust 2. Derbyshire County Council 3._ NHS England CORONER I am an Assistant Coroner, for the Coroner Area of Derby and Derbyshire. CORONER’S LEGAL POWERS I 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 9"" April 2013 an investigation was commenced into the death of Louise Sharon Henry. The investigation concluded at the end of the inquest heard between 2nd to 5" December 2014. The conclusion of the inquest was a narrative conclusion and a medical cause of death namely: 1a Aspiration pneumonitis and amphetamine excess consumption and at 2. Emotionally Unstable Personality disorder, paranoid psychosis. Narrative: Louise Sharon Henry had a long history of significant mental health problems with diagnosis of Emotionally unstable personality disorder, agoraphobia, panic disorder and probable paranoid psychosis. Following a home visit to Louise Sharon Henry on 18.2.13 by Consultant Psychiatrist from the Community Mental Health Team [CMHT] and lead professional namely a Social Worker from the Recovery Team of Derbyshire County Council [DCC], Louise Sharon Henry was discharged from mental health services provided to her from the CMHT and DCC Recovery team back to the care of the GP. The discharge process did not identify and communicate to the GP risk relapse triggers or a clear contingency plan in the event of a relapse or deterioration of Louise Henry’s mental health and did not identify if there was evidence of psychotic symptoms relating to Louise Sharon Henry believing neighbours were accessing her property then urgent reassessment would be required. Shortly after 4pm on 1.4.13 entry was forced to Louise Sharon Henry’s home at 70 Rothervale Road, Birdholme, Chesterfield by her eldest son who had become increasingly concerned for his mother’s welfare due to deterioration in her mental state. Louise Sharon Henry was found deceased in her bedroom sat at the bottom of her bed on a stool surrounded by opened blister packs of medication containing Diazepam, Omeprazole, Nitrazepam, Sertraline and Ibuprofen. These blister packs indicated that Louise Sharon Henry had not been taking her medication as directed. Next to Louise Sharon Henry was pink stained vomit containing undigested ibuprofen tablets. Toxicological examination of samples taken at post mortem confirmed consumption by Louise Sharon Henry of a substantial amount of amphetamine shortly prior to death. At the time of consuming the Ibuprofen and amphetamine Louise Sharon Henry was suffering from a relapse and deterioration of her mental state, including psychotic symptoms and experiencing and responding to auditory and visual hallucinations that neighbour’s were accessing her loft. Police and paramedics were called and attended the scene where life was formally pronounced extinct at 16.31 on 1.4.13 by the attending paramedic. CIRCUMSTANCES OF THE DEATH This can be seen in summary from the narrative conclusion set out. Following a home visit to Louise Sharon Henry on 18.2.13 by Consultant Psychiatrist from the Community Mental Health Team [CMHT] and lead professional namely a Social Worker from the Recovery Team of Derbyshire County Council [DCC], Louise Sharon Henry was discharged from mental health services provided to her from the CMHT and DCC Recovery team back to the care of the GP. The discharge process of Louise Henry from the mental health services provided to her by DCC Recovery Team and CMHT just over a month before her death did not identify and communicate to the GP risk relapse triggers or a clear contingency plan in the event of a relapse or deterioration of Louise Henry’s mental health and did not identify if there was evidence of psychotic symptoms relating to Louise Sharon Henry believing neighbours were accessing her property then urgent reassessment would be required. In the past when Louise Henry had experienced psychotic symptoms relating to her neighbours accessing her home she had taken overdoses and the risk of accidental or deliberate overdose was known. The lead professional had not written to the GP to inform of her discharge of Louise Henry from DCC Recovery Team. The psychiatrist had written to the GP informing them of her discharge but the letter did not identify risk relapse triggers. In respect of Louise Henry I heard evidence that the risk relapse triggers were well known and had been identified prior to her discharge from mental health services. I also heard evidence that prior to her death Louise Henry had contacted the police indicating that neighbours were accessing her loft [on 12.3.13, 24.3.13 and 31.3.13] and this information had been made known to mental health services previously supporting Louise Henry namely the CMHT [on 15.3.13] and DCC Recovery Team [18.3.13] but there was no reassessment of Louise Henry and her mental health prior to her death. A previous worker of Louise Henry’s from the CMHT passed information provided to her from the police to the GP on 15.3.13 without a request being made for assessment of Louise Henry. 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. — DCC and Derbyshire Healthcare NHS Foundation Trust. 1. The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co- ordinators for the purposes of the Care Programme Approach [CPA]. I heard evidence that the Psychiatrist from the CMHT understood that the social worker from the DCC Recovery Team was Louise Henry’s Care coordinator for CPA purposes and was following the Care Programme Approach. I also heard evidence that when the services of the DCC Recovery Team and CMHT ceased to be an Integrated service the understanding of the psychiatrist had been that the DCC Recovery Team workers would be following the CPA. I heard evidence from DCC Recovery Team that this was not the case and that they were not following the CPA or acting as the care co-ordinator for the purposes of CPA but instead worked to the Self Directed Support framework. It is important that the CMHT understand the roles and responsibilities of the Lead professional from the DCC Recovery Team and that they are not following the Care Programme approach or acting as the care co- ordinator. It is of concern that workers from the CMHT and DCC Recovery Team who often are involved in providing multi agency mental health services and joint working to patients misunderstand each others roles, responsibilities and processes. The care co-ordinator is a key role in the management of a patient with mental health difficulties and it is important that there is no ambiguity in respect of who is acting in this capacity. 2. That both the CMHT and the Recovery Team of DCC ensure that when discharging patients all necessary processes and procedures indicated in policies are followed by the lead professional and / or care co-ordinator and that discharge letters sent to GPs and to patients identify risk relapse triggers and indicators to ensure re-assessment if there are signs of deterioration in mental health and speedy referral back to secondary mental health services if required. My concern is that the processes and procedures indicated on discharge for Louise Henry were not followed and the confusion as to roles and responsibilities risks this re-occuring. 3. There is a misunderstanding in respect of the Recovery Team from DCC and the Recovery Team within the CMHT and potential for confusion between professionals and service users due to there being 2 services operating under the title “Recovery Team” operated by different agencies namely DCC and the CMHT. NHS England 4. That GPs do not appreciate the use that can be made of the Special Patient Note facility and Right Care plan facility on the EMIS system operated by GPs. I heard evidence that key information relating to patients and in particular mental health patients can be updated on to the Special Patient Note facility and the Right Care Plan facility by GPs and used to record risk relapse triggers and indicators for patient’s with mental health difficulties and risk of suicide/ self harm. This enables Out of Hours Services such as those operated by Derbyshire HealthCare United to access key risk information when they are called out of hours when the GP and the full GP records with this key information is not available. There appears to be action that can be taken by NHS England through the Clinical Commissioning Groups to educate GPs as to this facility. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe: Derbyshire County Council; Derbyshire Healthcare NHS Foundation Trust; NHS England 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 13th March 2014. I, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, the family care of | DCC, Derbyshire Healthcare NHS Foundation Trust, Derbyshire Health United, I 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] 1.1.15 [SIGNED BY CORONER] Gen” Curhoragre
2 responses 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.
[5 penevsnine Derbyshire Healthcare [W/7h9 improving life for local people NHS Foundation Trust Acting Strategic Director Corporate & Legal Affairs Derbyshire County Council | Trust Headquarters Adult Care | Kingsway Site r County Hall Derby / Matlock | DE22 3LZ i Derbyshire _--| . DE4 3AG “Telephone: nn Telephone: Fax: Fax: Miss Sophie Cartwright Coroner’s Court 5-6 Royal Court Basil Close Chesterfield Derbyshire $41 7SL 12 March 2015 Dear Miss Cartwright i LOUISE SHARON HENRY DATE OF DEATH: 2 APRIL 2013 | DATE OF INQUEST: 2-5 DECEMBER 2014 This response has been prepared by Derbyshire County Council and Derbyshire Healthcare NHS Foundation Trust as a result of HM Coroner issuing a report under para 7, schedule 5 of the Coroners’ and Justice Act 2009 and regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013. During the course of the inquest the evidence revealed matters giving rise for concern to the Assistant Coroner. In her opinion, there is a risk of future deaths occurring unless action is taken. The matters of concern identified by the Assistant Coroner for both Derbyshire County Council (“the Council”) and Derbyshire Healthcare NHS Foundation Trust (DCHFT) to address can be summarised as follows: ° Lack of understanding amongst professionals regarding roles and responsibilities ° Failures within the discharge process e Misunderstanding regarding the responsibility of the “Recovery Team” 1[Page The Council and DCHFT have carefully considered the contents of the Regulation 28 report together with the evidence heard at the inquest and reviewed the matters referred to with senior managers within DCHFT. Whilst the Council and the DCHFT are keen to address the areas of concem identified by the Assistant Coroner, it is of the opinion that some knowledge of the historical context of the service is useful in terms of identifying corrective actions. Background — Mental Health Service Provision in Derbyshire The service has undergone extensive development since 2013. Historically, adult health and social care mental health services were organised and managed as an almost fully integrated programme in Derbyshire. Social workers employed by the Council were based in the same buildings as the nurses and health care professionals employed by the Trust. Over time this resulted in the social workers taking on responsibility for monitoring mental health, medication regimes and medical care planning. The national policy focus on the personalisation of adult social care services had the effect of returning the integrated organisation and management of mental health services to two separate organisations that had the capacity to collaborate and co-work cases. This meant that social workers could return to focusing on social care needs and the mental health professionals could more directly focus upon specific mental health interventions. This organisational adjustment started in 2011 and involved a great deal of upheaval. It was a difficult time for the personnel involved and it is acknowledged by the Council that there was, for a time, some uncertainty about the division of roles and responsibilities. Senior management at the Council and DCHFT addressed this by reviewing expectations and planning for the future. However, it is often the case that it can take some time to embed new organisational arrangements, and policies and procedures into practice, especially after an extensive alteration to the service. A team of managers from both the Council and DCHFT negotiated the new roles for each element of the service. Attached herewith is a copy of a document titled “Referrals from Derbyshire Healthcare NHS Foundation Trust to Derbyshire County Council (Appendix 1). This document sets out in section 1 the agreed division of responsibilities where the case is social care led. 2|Page np In January 2012, the overall caseload dealt with by the Mental Health Service (both health and social care) was divided by service user primary needs. Those who were deemed to have primary social care needs were allocated a social worker as their lead professional. Those with primary mental health needs were allocated a healthcare lead professional (referred to by healthcare as a Care Coordinator). Miss Henry was deemed to have a greater need for social care support at the time and that is why MN, employed by the Council as a social worker and Approved Mental Health Professional was allocated as her lead professional. — HI continued in the role of Miss Henry's Consultant Psychiatrist to monitor her mental health with annual Care Programme Approach (“CPA”) reviews and amend her medication as required. Taking into account this historical context and following discussions with the Trust, the Council’s proposed actions for addressing the 3 areas of concern identified by the Assistant Coroner are set out below: MATTER OF CONCERN 1 — ROLES AND RESPONSIBILITIES The evidence presented to the Assistant Coroner indicated the following areas of concern: « The Community Mental Health Team, including the Psychiatrist, did not understand the roles and responsibilities (including the correct procedure) undertaken by the Council’s “Recovery Team”. e — There was lack of clarity as to whether the social worker was following the Care Programme Approach or Self Directed Support (“SDS”) framework. e There may be an ambiguity as to who acts as “Care Co-ordinator.” In order to address these concerns the Council and DCHFT intend to review:- ACTIONS 1. The case of Miss Henry demonstrated that there was a misunderstanding amongst professions as to roles and responsibilities of mental health services workers. The Council and DCHFT intend to review this matter at the forthcoming “Service Manager Interface Meeting” to be held on 27 March 2015. This is a joint meeting between the Council and DCHFT. The clarification of respective roles and responsibilities of mental health and social care workers will be the focus of these discussions. 3|Page 2. Preliminary discussions have already taken place between Health and Social Care senior managers about the interface between CPA and SDS. Both organisations are clear that the two policies are intended to be complementary. It is acknowledged there may be cases where the individual is subject to CPA but where a social worker is the lead practitioner. The Council is clear that in following SDS, this will also fulfil the requirements of CPA. A plan involving senior managers from both organisations has been agreed to update the DCHFT Care Programme Approach Policy to provide clearer updated guidance upon this issue. 3. Within the Council it has been acknowledged that there needs to be a sound understanding of what our services do and how they do work together to support those people in need of skilled care and support. The Council therefore plans to place a feature about the Fieldwork (Mental Health) (formerly known as the “Recovery Team”) in the next Practice Bulletin which we shall distribute to all teams including the Children and Younger Adults Department and the Trust. This will also serve to publicise the rebranding of the team described below. This information will also be shared with DCHFT colleagues. 4. The Council has also established that there is still some work to be done in terms of education for health and social care workers. on the expectations of each service pathway. The outcomes of the Service Manager Interface Meeting described above will be cascaded down to staff via line management supervision. MATTER OF CONCERN 2 — DISCHARGE PROCESS The evidence presented to the Assistant Coroner indicated the following areas of concern: e Discharge letter to the GP did not identify risk relapse triggers . This could impact on the potential for reassessment in the case of a subsequent deterioration in mental health In order to address these concerns, the Council has put in place the following actions: ACTIONS COUNCIL 4. The Council is clear that the discharge arrangements set out in its Self- Directed Support (“SDS”) policy must be properly applied in every case. This is the policy relevant to social workers, NOT the Care Programme Approach (“CPA”) although they are intended to be complementary. Adherence to this policy ensures that following the decision to discharge someone from social care support they are properly informed as to the reasons for this decision and any alternative sources of support. 2. The Council is satisfied that since Miss Henry's death, the SDS framework has been further embedded into social work practice and all discharges are more structured and robust. 3. The service user will have a review to discuss whether they feel that they continue to require support. If they are discharged, they receive a 4/Page nn i I i written discharge plan explaining that they have been discharged from the service. The letter also contains the contact numbers for those agencies continuing to provide care and also information on what to do if they feel that they require support in the future. This letter is shared with all of the agencies involved so that there is a clear and agreed plan of discharge. A copy is also sent to the GP. Enquiries are made of the service users as to what plans they have in place to manage to crisis. This will be included in the discharge plan. 4. The Council has initiated a review of how Adult Care Mental Health workers manage risk within the service. A “Task and Finish Group” was t set up in January 2015 to ensure social workers work consistently and i robustly in managing risk to include compliance with SDS procedures, including where a person is discharged. This Group will also work collaboratively with the Trust and other Health colleagues where appropriate. In addition, the Council intends to email all relevant fieldwork staff with a reminder of the SDS processes, particularly the arrangements to be followed on discharge. 5. The Council is satisfied that, if applied correctly, the existing policy would ensure that upon discharge a letter would be written to the client’s GP setting out the reasons for the discharge decision and would identify any risk triggers and indicators to ensure that there would be a re- assessment and possible reinstatement of support if there are signs of a deterioration in mental health. 6. To ensure there is consistency across all cases, an audit will be undertaken in respect of a sample of recently closed cases to confirm adherence to the SDS discharge procedure. This will better inform Adult Care senior management as to whether further staff training is required. ACTIONS DCHFT 7. A staff briefing has been circulated raising awareness relating to this issue across DCHFT. 8. Aplan has been agreed to update the Care Programme Approach Policy and Discharge, Transfers/Transition Policy to provide clearer updated guidance upon discharge planning particularly in relation to communications with GPs. 9. The issue will be raised at the Trust Medical Advisory Committee to raise awareness with all DCHFT psychiatrists. 5|Page 10. A benchmark it_and follow up audit of discharge letters is to be conducted b 41. On completion of the audit, a review of the discharge letter format available within the PARIS system will take place and it will be amended accordingly. New templates will be configured which will alert GPs to information they should enter onto the ‘special patient notes’ facility. MATTER OF CONCERN 3 — USE OF TERM “RECOVERY TEAM” The evidence presented to the Assistant Coroner indicated the following area of concern: ° 2 services using the term “recovery team”, namely the Council and the Trust's Community Mental Health Team (often referred to as the “CMHT”) could lead to confusion amongst both professionals and service users. In order to address this concern the Council intends to do the following: ACTIONS 4. The Council accepts that 2 teams from different agencies being called the same name could lead to confusion. The Council therefore intends to “rebrand” its recovery team as “Fieldwork (Mental Health)’. This reflects the description given to the other, generic social care teams which are known as Fieldwork teams. 2. This renaming of the team will be launched by the Council at the next scheduled Social Care Forum on 24 March 2015. It will be put on the next Practice Bulletin which will be distributed to all Adult Care and Children and Younger Adults staff within the Council as well as health colleagues. It will also be put before the forthcoming Health and Social Care Interface meeting on 27 March 2015. ACTIONS DCHFT 4. DCHFT is currently undergoing a transformation and is in the process of developing Neighborhood community provision. It is likely that within this process the term Recovery Team will no longer be used. New terminology will be in place by November 2015 and DCHFT will be mindful of the need for clarity between organisations. 6|Page The Council and DCHFT recognise the issues that were raised during the Inquest and your subsequent Regulation 28 notice and we hope this response and subsequent work we have jointly planned will satisfy you that we have taken these issues seriously and will do our utmost to further develop and strengthen our policies and procedures for the future. : — Steve Trenchard Acting Strategic Director Chief Executive Officer Adult Care Yours sincerely 7[Page
INHS) England Medical Directorate Derbyshire & Nottinghamshire Area Team (NHS England) Birch House Ransom Wood Business Park Southwell Road West Mansfield Your Ref: Notts Our Ref: IM/EC NG21 OHJ Please ask fo: —_—_—_—__ Tel No: 01138255503 Email : Date: 19” August 2015 STRICTLY PRIVATE & CONFIDENTIAL FOR ADDRESSEE ONLY Sent via email Dear Colleague Re: Special Patient Notes and Right Care Plans | have been asked to remind you about the use of Special Patient Notes and, where available, Right Care Plans particularly in relation to patients with mental health conditions following a Regulation 28 report to prevent future deaths from the Coroner's Office. At a recent inquest the Derbyshire Assistant Coroner heard that the Out of Hours service did not have access to any information relating to a patient with a serious mental health condition. In particular, there was no information regarding relapse triggers or a clear plan of action in the event of a significant relapse. Had this information been available to the Out of Hours service it would have meant that the clinicians involved would have been better placed to risk assess the patient and it is possible that a tragic death may have been avoided. Following receipt of this report a review of information sharing with one Out Of Hours provider showed that of 444 new plans only 29 related solely to mental health conditions. The vast majority of plans were for complex medical conditions. This suggests that Special Patient Notes and Right Care Plans are less frequently completed for patients suffering from significant mental health problems and that this situation could be improved. | recommend that practices review their Serious Mental Illness registers to ensure that appropriate patients are identified that should have information shared with Out of Hours providers. Clearly patients such as the one in this case who have clear relapse triggers or indicators that their condition is deteriorating putting them at risk of harm should have this information shared. | understand that the Medical Interoperability Gateway has been introduced in parts of Nottinghamshire and will be rolled out to the rest of the county and also across Derbyshire. This allows access, with patient consent, to read coded information in the patient’s medical record. This in time should improve record sharing. | would be grateful if you would review your patients with serious mental health conditions to ensure appropriate information is available to Out of Hours services to allow them to effectively manage such patients. Yours sincerely Deputy Medical Director
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.