Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0044, written 2 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Feb 2015 |
|---|---|
| Reference | 2015-0044 |
| Deceased | George Taylor |
| Coroner | Andrew Cox |
| Coroner area | Cornwall |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Cornwall Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A 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 IS BEING SENT TO: 1. Mrs J Youart, Managing Director, Kernow Clinical Commissioning Group, Sedgemoor Centre, Priory Road, St Austell, Cornwall, PL25 5AS 2. Mr J Hunt, Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall, LONDON, SW1A 2NS 1 CORONER I am Andrew Cox, Assistant Coroner for the coroner area of Cornwall, New Lodge, Newquay Road, Penmount, TRURO, TR4 9AA 2 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. 3 INVESTIGATION and INQUEST On 12 July 2013 I commenced an investigation into the death of George Allan Taylor aged 80. The investigation concluded at the end of a two day jury inquest on 3 February 2015. The jury made a determination that Mr Taylor committed suicide. 4 CIRCUMSTANCES OF THE DEATH Mr Taylor had a past medical history that included mental health issues. On 25 July 2012 he took an overdose of medication and subsequently spent 7/8 months as an inpatient at Longreach Psychiatric Hospital in Camborne/Redruth, Cornwall. He was discharged in March 2013. On 24 June 2013 Mr Taylor took a second overdose of medication. He was described as despondent and having feelings of hopelessness at the time. This was believed to be related to the fact that his wife, who was everything to him, suffered from dementia and no longer recognised him. Mr Taylor was assessed in Royal Cornwall Hospital Truro in Cornwall. It was felt that an informal admission into hospital may be appropriate. Mr Taylor agreed with this. An acute psychiatric hospital bed was not immediately available. The next day Mr Taylor’s treatment plan changed and it was felt appropriate that he could be managed in an Interim Assessment And Treatment Bed in a care home. He also developed norovirus and needed to remain in hospital for a few days. An acute psychiatric bed did become available but the consultant treating Mr Taylor no longer felt that this was needed. When an acute psychiatric bed was not immediately available consideration was given to sending Mr Taylor to an out of county bed. This was notwithstanding the fact that it 1 was recognised one of the features of his previous suicide attempts was his social isolation On 28 June 2013 Mr Taylor moved to The Brake Manor care home near St Austell. On 30 June Mr Taylor said he wanted to return home. On 1 July Mr Taylor was seen by the Home Treatment Team and his Care Co-ordinator who was a Community Mental Health Nurse. Mr Taylor was adamant that he would not remain in the care home. A team decision was reached that Mr Taylor remained at high risk of deliberate self- harm. It was felt, however, that Mr Taylor had capacity and there were no grounds for seeking his informal admission into hospital or convening a Mental Health Act assessment. It was agreed that Mr Taylor could return home under the daily supervision of the Home Treatment Team. On 2 July the Home Treatment Team attempted to contact Mr Taylor at home but he was found hanged. During the evidence I heard from Cornwall Partnership Foundation Trust responsible for inpatient care. She said that, in recent years, there has been an increase in demand for acute psychiatric beds (in keeping with the national picture) but no additional allocation of beds has been provided. This has resulted in 8 to 12 patients per month typically having to go out of county for treatment. She was of the view that there was an inadequate provision of acute psychiatric beds in Cornwall. who is an Associate Director at The inquest also heard from She advised that for the year 2013/14 the cost of treating Cornish acute psychiatric patients out of county was £1.4 million. from Kernow Clinical Commissioning Group. also stated in evidence that resourcing for the Home Treatment Team, the gatekeepers for acute psychiatric beds, fell below nationally benchmarked standards. told the inquest that a review between Cornwall Partnership Foundation Trust and Kernow Clinical Commissioning Group is currently underway looking at all services and the allocation of resources. 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. – It was established in evidence that Mr Taylor’s death was not caused by the lack of an acute psychiatric bed. Furthermore, it was established that no patient had died out of county because an in county acute psychiatric bed was not available. It was further established that no patient had died in Cornwall while waiting for an acute psychiatric bed to become available That said, it appears far from desirable that 8 to 12 patients are being sent out of county per month due to a lack of acute psychiatric beds. It is easy to see that, with only a small change in circumstances, a future death could result as a consequence of a lack of acute psychiatric beds. 2 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 3 April 2015. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the following: His Honour Judge, Peter Thornton QC, the Chief Coroner of England & Wales, the family of Mr Taylor and Cornwall Partnership Foundation Trust, an interested person at the inquest proceedings. 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. 9 6th February 2015 Andrew J Cox 3
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.
abs Department | of Health POC3000928796 Mr Andrew Cox i HM Assistant Coroner for the County of Cornwall The New Lodge Newquay Road Penmount Truro TR4 9AA From Norman Lamb MP Minister of State for Care and Support Richmond House 79 Whitehall London SWIA 2NS Tel: 020 7210 4850 26 MAR 2015 Thank you for your letter to the Secretary of State for Health about the death of George Taylor. I am responding as Minister responsible for mental health policy. I was saddened to hear of Mr Taylor’s death. The Government has made it clear that beds must always be available for those who need them and have set out in the Mandate — our annual contract with NHS England — that plans must be put in place to ensure no one in mental health crisis will be turned away. I have made NHS England aware of yout report. The Crisis Care Concordat makes it clear that local commissioners should commission a range of mental health services that respond rapidly and appropriately to a person in urgent need, We asked local areas to commit to and agree their own ‘Mental Health Crisis Declaration’ before the end of 2014. Every area in England has done so and work is now underway across the country to develop action plans over the coming months detailing how local partners will improve crisis care for people of all ages. As you heard during the inquest, the local Clinical Commissioning Group (CCG) is reviewing bed provision in Cornwall with the Cornwall Partnership Foundation Trust. Decisions about the appropriate number of beds to be commissioned in Cornwall are for local clinicians to make. I note that you have also sent your report to the CCG, I hope that this information is helpful and I thank you for bringing the circumstances of Mr Taylor’s death to our attention. YA ; ee Sam ' NORMAN LAMB we
NHS Kernow Clinical Commissioning Group Joy Youart Managing Director Date: 19 March 2015 Sedgemoor Centre Priory Road Your Ref: AJC/akd St Austell PL25 5AS Mr Andrew J Cox Assistant Coroner for the County of Tel: c/o 01726 627907 Cornwall The New Lodge — Newquay Road Penmount TRURO TR4 9AA Dear Mr Cox Re: George Allan Taylor deceased Please find NHS Kernow’s response to the Regulation 28 report to prevent future deaths in respect of Mr Taylor. Commissioned services NHS Kernow commissions a range of mental health and well-being services based upon local performance, activity data and prevalence data from the annual Joint Strategic Needs assessment undertaken by Colleagues in Public Health, local needs analysis, national benchmarking data and stakeholder feedback. This pathway includes services to support the health and well-being of the individual through a variety of 3rd sector services, employment support, ethnic minority group support, befriending services and community groups as per the Living Well model, which is being rolled out across the County and has national Pioneer status. Two Providers deliver Primary Care Psychological interventions using an Any Qualified Provider contract. 95% of mental ill-health is dealt with in Primary Care by GPs, and NHS Kernow is committed to ensuring resources are utilised appropriately to support people to access prevention and well-being services, thus reducing the need for specialist health intervention. (Continued) Chair: Dr Colin Philip Managing Director: Joy Youart Head office: 01726 627800 enquiries@kernowccg.nhs.uk www.kernowccg.nhs.uk Sedgemoor Centre, Priory Road, St Austell, Cornwall, PL25 5AS o0e00 /nhskernow NHS) Kernow Clinical Commissioning Group Specialist Secondary care mental health and learning disability services form part of the pathway for individuals who require specialist assessment, intervention and treatment. These are commissioned from Cornwall Partnership NHS Foundation Trust (CPFT) who provide community based and in-patient services. NHS Kernow commissions 54 acute mental health assessment and treatment beds from CPFT. This is in addition to 8 Psychiatric Intensive Care beds, 18 recovery and rehabilitation beds and 24 complex care and dementia beds. Occasionally there is a need to place people in out of county acute mental health beds when availability in county has reached capacity. The least restrictive option is first priority for patients, and the decision to admit is a clinically-led one by CFT specialist clinicians. NHS providers are the first point of contact to source a bed. NHS Kernow also has a contract with Cygnet Hospitals for acute mental health beds and other specialist in-patient services. This enables the CCG to oversee the performance and quality monitoring of the Provider to ensure Cornwall and Isles of Scilly residents receive safe, timely and therapeutic interventions and are repatriated back to Cornwall as quickly as possible. As part of the health and social care community commitment to implementing the National Crisis Care concordat, NHS Kernow is working with Cornwall Partnership NHS Foundation Trust ,Royal Cornwall Hospitals Trust, service users and other providers to develop alternatives to hospital admission and to ensure the individual receives assessment and intervention as early as possible. This includes a notional budget assigned to Cornwall Partnership NHS Foundation Trust to implement the least restrictive option by delivering care to the individual in the community and prevent admission to hospital. The ‘alternative funding’ will facilitate access to a range of interventions that meet the needs of the individual as evidenced in the individual’s written care plan. This work commenced in October 2014 and will be reviewed in 2015 to assess the impact for individuals and the whole system. NHS Kernow is actively working with Cornwall Partnership NHS Foundation Trust and providers to review current provision and the needs of individuals who due to complex need and demand issues, are placed out of county. This review will inform future commissioning and service delivery. | hope you find this update helpful. Yours sincerely, re, | ox Vay Joy Youart Managing Director oe Oa Page 2
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