Prevention of Future Deaths reports · 2015

Louise Henry

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 report16 Jan 2015
Reference2015-0013
DeceasedLouise Henry
CoronerSophie Cartwright
Coroner areaDerby & Derbyshire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

Responses

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.

Response from Derbyshire Healthcare NHS Trust (PDF)
[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

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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
Response from NHS England (PDF)
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

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