Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0069, written 19 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 | 19 Feb 2015 |
|---|---|
| Reference | 2015-0069 |
| Deceased | Alexander Ball |
| Coroner | David Roberts |
| Coroner area | Cumbria |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Cumbria University Hospitals NHS Trust · Cumbria Partnership NHS Foundation Trust |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS RE: ALEXANDER GEORGE BALL Deceased THIS REPORT IS BEING SENT TO: 1. RR - cumbria Partnership NHS Foundation Trust CORONER lam David Llewelyn Roberts, senior coroner, for the coroner area of Cumbria. 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 On 26" February 2014 | commenced an investigation into the death of Alexander George Ball, Age - 50. The investigation concluded at the end of the inquest on the 29" January 2015. | 4 | CIRCUMSTANCES OF THE DEATH (3) On the night of the 20" February 2014 the deceased was found unresponsive lying on his bed at his home at 5 The Crescent, Thornhill. He was on a methadone programme and prescribed antidepressants. He also accessed illicit drugs including diazepam, phenazepam, heroin and cannabis in the days before his death. He saw a Psychiatrist on the 7 January, his General Practitioner on the 11 February and his Drugs Counsellor on the 20"" February. He was on a waiting list for the allocation of a Care Co- ordinator. He died as a result of ingestion of both prescription and illicit drugs. This followed a deliberate overdose of street diazepam on about the 1“ February and recommencing the use of heroin on about the 16" February. There is no evidence that the ingestion of the drugs which resulted in his death was done with the intention of ending his life. On the balance of probabilities the appointment of a Care Co-ordinator would have aided communication between those caring for him, and that an earlier re- referral to Mental Health Services may have resulted in benefits to his mental wellbeing. 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. — There was a lack of communication between the Partnership Trust and other agencies. The position was exacerbated by the absence of a dedicated Care Co-ordinator. 6 | ACTION SHOULD BE TAKEN Cumbria Partnership Foundation Trust to take action and engage with its health Partners in learning lessons from the death of Mr. Ball and drawing conclusions on how services might be improved to secure better outcomes for Patients Presenting with complex needs. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 16th April 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. all or of 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Parents) (Sister) 1) | have also sent it to ee: 2) Ann Farrar — Chief Executive — North Cumbria University Hospitals NHS Trust 3) Bev Humphrey — Chief Executive — Greater Manchester West Mental Health | 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. response, about the release or the publication of your response by the Chief Coroner. NHS Trust. He may send a copy of this report to any person who he believes may find it useful interest. You may make representations to me, the coroner, at the time of your Jn [9 | 49th February 2015 [SIGNED By CORONER]
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.
Cumbria Partnership |NHS| Your Ref: Po NHS Foundation Trust Our Ref: | (ie wi Date: 17 April 2015 coaraee Private and Confidential Ww Mr D.L.1. Roberts H.M Senior Coroner Happier | Healthier | Hopeful Fairfield Station Road Cockermouth Cumbria CA13 9PT Dear Mr Roberts, Re: Inquest into the death of Alexander George Ball dated 29 January 2015 | am writing in response to your letter dated 19 February 2015, issued under Regulation 28 and pertaining to the death of Mr Alexander George Ball. The Trust has noted the points you raised during the inquest which were subsequently highlighted within the Regulation 28. The Trust has also noted from your letter and your summary comments made at the time, that copies have been sent to the other agencies involved in Mr Ball's care but that the lead agency identified under section 6 is Cumbria Partnership NHS Foundation Trust in view of the fact that the Trust had taken the lead role in the Serious Untoward Incident investigation. We note that your comments were equally directed at the other parties, namely the North Cumbria University Hospitals NHS Trust, Mr Ball’s General Practitioner and Greater Manchester West Mental Health NHS Foundation Trust as the providers of the UNITY drug and alcohol recovery services. As acknowledged during the inquest, the Trust has undertaken significant work through the internal investigation process and the provision of the consequent action plan. Since the inquest, the Trust has reviewed the points you raised in respect of the two issues identified in the Regulation 28. In regards to the first issue, that of communication between the partner agencies, our understanding was your specific concerns related to:- e At the time of Mr Ball's admission into hospital on 9 February 2014 North Cumbria University Hospitals NHS Trust staff were focused on his physical care and did not think in mental health terms. Consequently there was no communication with the Mental Health Team; @ |) aa Kindness Fairness Ambition =: Die Mr D.L.1. Roberts 16 April 2015 e Following the above admission to the emergency department there was no formal communication between UNITY staff and the Mental Health Team with regards to Mr Ball's ongoing mental health care needs; e Mr Ball’s GP did not increase the fluoxetine, despite the recommendation made by our consultant psychiatrist and there was no communication between his GP and the consultant psychiatrist in relation to any differences in clinical opinion. As detailed in the Serious Untoward Incident action plan, the Trust will facilitate an Oxford Learning Event with the identified partner agencies. The purpose of this event is to identify and address the issues of communication ensuring clarity over the pathway for clients presenting with both mental health problems and substance misuse problems across the various care groups. We plan to hold this event during June 2015 subject to agreement with partner agencies. Prior to the Oxford Learning Event, | have requested that a range of immediate actions are introduced by the Trust’s Mental Health Care Group in order to improve communication arrangements with partners. These improvements include:- e Monthly meetings between key staff from the Trust's Mental Health Care Group and local UNITY team members. These meetings will take place at a locality level with the aim of providing a direct conduit for face to face communications. e The monthly meetings will be supplemented by a county wide quarterly liaison forum which will provide feedback to the Trust’s Mental Health Care Group Clinical Governance group. The emphasis of these meetings will be to enhance multi-agency communications with improved outcomes for patients presenting with complex needs across services within Cumbria. The above actions will be implemented by the end of April 2015. With regards to the second concern you raise in respect of the lack of a permanent care coordinator, the Trust has set an internal measure relating to the maximum waiting times patients should expect for the allocation of a care co-ordinator. At the time of Mr Ball’s death there were 74 patients on the waiting list to be allocated a care co-ordinator within our Adult community mental health service in Copeland. The internal measures to address this area are being supported by clinical leads within the service including responsibility for the active management of the waiting list and undertaking robust caseload reviews and supervision. Trust Headquarters| Voreda House|Penrith | Cumbria] CA11 300 T: 01228 602128 | E: PET@cumbria.nhs.uk |www.cumbriapartnership.nhs.uk = Se Mr D.L.I. Roberts 16 April 2015 This has had the impact of ensuring that timely discharges and transfers take place, enabling capacity to be released to allocate new cases. The measures being undertaken with Copeland will be rolled out across the Trust during 2015. | hope that the above information highlights the actions taken by the Trust to address concerns relating to the quality of services it provides to the local community. | also want to assure you that we at the Trust take very seriously our responsibilities for providing safe and effective care in all areas of our services and in our relationships with our partner agencies. Should you require clarification or further information with regards to any of the points raised above please do not hesitate to contact me directly. Yours sincerely, Clare Molloy Chief Executive Copies to: Ann Farrar, Chief Executive, North Cumbria University Hospitals NHS Trust Bev Humphrey, Chief Executive, Greater Manchester West NHS FT Trust Headquarters| Voreda House|Penrith | Cumbria] CAaza 300 T: 01228 602128 | E: PET@cumbria.nhs.uk |www.cumbriapartnership.nhs.uk
Greater Manchester West NHS) Mental Health NHS Foundation Trust Chair and Chief Executives Office Trust Headquarters 234 March 2015 24 MAR 2015 Bury New Road . Manchester Mr David LI Roberts M25 3BL Her Majesty's Senior Coroner aT Fairfield Fax. Station Street Web: www.gmw.nhs.uk Cockermouth palsies CA139PT Ea 2 vo Dear Mr Roberts Response to the Regulation 28 letter issued to the Cumbria Partnership NHS Foundation Trust on the 19" February 2015. Following the inquest heid on the 2S" January 2015 into the death of Mr Alexander George Ball | am writing to respond to the Regulation 28 letter you shared with this Trust following the conclusion of your inquiry into Mr Ball's death. Before | respond however | would like to offer my sincere condolences to Mr Ball's family for their loss. | thought it appropriate that | should respond to assure you and Mr Ball's family of the work we are doing to improve the care and treatment pathways of those service users who access our services and the collaborative work between ourselves and Cumbria Partnership NHS Foundation Trust (CPFT). Unity are actively involved in the Cumbria wide Crisis Care Concordat , a working group committed to supporting individuals experiencing a mental health crisis to get the care they need appropriately. Unity Carlisle are members of the Frequent Attenders in the Carlisle and Eden Health Economy meetings and are actively working with partners to provide a joined up approach to managing those individuals with the most complex care needs. It is usual clinical practice for Unity to attend and organise interdisciplinary team meetings with CPFT to formulate appropriate care plans for patients with complex care needs. During reviews of serious clinical incidents by Unity, it is common practice by Unity to invite team members from CPFT when appropriate. These can be opportunities to develop joint learning outcomes and to describe working practices within each organisation. Unity is committed to the continuation and strengthening of these working practices. | hope this response offers you and Mr Ball’s family assurance and demonstrates how committed the Trust and particularly our Unity service are to improving the services in Cumbria for service users with mental health and substance misuse needs. Yours sincerely Bev Humphrey Chief Executive The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment. Greater Manchester West Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. oe Triangle of Care Chair: Alan Maden Chief Executive: Bev Humphrey MEMBER
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