Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0113, written 23 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Mar 2015 |
|---|---|
| Reference | 2015-0113 |
| Deceased | Barbara Mayer |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Suffolk 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Norfolk and Suffolk NHS Foundation Trust Trust Management “4° Floor Admin Hellesdon Hospital Drayton High Road Hellesdon Norwich NR6 5BE 1 | CORONER tam JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK 2 | 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 17 November 2014 | commenced an investigation into the death of Barbara Mary Anne Mayer Aged 72 years. The investigation concluded at the end of the inquest on 11 March 2015. The conclusion of the inquest was medical cause of death: drowning; and conclusion: “Suicide whilst under the care of Mental Health Services’. 4 | CIRCUMSTANCES OF THE DEATH. Mrs Mayer had a tong history of depression. Her anxiety increased in 2013 when she suffered a number of physical health problems. She was reviewed regularly by her GP who referred her for a mental health assessment in September 2014. Her care was passed to the Dementia and Complexity in Later Life Team. She continued to ask her husband to help her end her life. She was discharged by the Crisis Team to the Community Mental Health Team on 15 October 2014. Her GP referred her back to the Crisis Team for assessment on 12 November 2014. On 14 November 2014, Mrs Mayer begged her husband to help drown her in the bath. [EE called the Crisis Team who were unable to attend due to levels of work elsewhere. Her Care Co-Ordinator did attend to see her. [was contacted by the Crisis Team to say someone would be visiting that day. At 21:15 hours a telephone call was made to say someone would attend after midnight for an assessment. As Mrs Mayer had taken sleeping medication and was getting ready for bed, it was agreed someone would call to see her the next morning. At some time between.02:00am and 05:00am Mrs Mayer left the house, leaving a pillow in her bed in place of her body. She was found on 16 November 2014 drowned in a nearby pond. 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. — (1) MA was noted to show signs of Carer fatigue, but this was not followed up; (2) Although seen regularly by the Crisis Team, Mrs Mayer was seen by a number of different people as a result of which no trusting relationship could be established. She had to repeat her history at each visit to a different person about personal matters. (3) Different treatments were offered to Mrs Mayer without the reasoning or their efficacy being discussed with her. : (4) Mrs Mayer required help urgently on 14 November 2014 but due to an increase in demand no one was available to see her until 16 November 2014. It is understood Doctors are now called out and ‘an On call Manager can be contacted in such situations. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 22 May 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 Person: HE Mayer (husband). | 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: 23 March 2015 SIGNED BY CORONER
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.
Norfolk and Suffolk INHS| NHS Foundation Trust Trust Management 1* Floor Admin Hellesdon Hospital Drayton High Road 2.6 MAY 015 en ealesdon Norwich NR6 5BE Our Ref: MS/mp 20 May 2015 Private and Confidential Ms J Lake HM Coroner Norfolk Coroner's Service 69-75 Thorpe Road Norwich Norfolk NR1 1UA Dear Ms Lake Regulation 28 report following the inquest of Mrs Barbara Mayer on 11 March 2015 | write in response to your report dated 23 March 2015. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the death of Mrs Mayer on 11 March 2015. You recorded four areas giving rise to concern. | will address these in order: 1. | showing signs of carer fatigue, but this was not followed up Caring for someone with mental health needs is a challenging experience and can have mental and physical effects. It is imperative that carers are supported in their role and provided with proportionate assistance when required. In EEE case we did not fully appreciate the impact of caring was having. For this, the Trust apologises. The Trust is implementing the ‘Triangle of Care’ model which prescribes a therapeutic alliance between service user, carer and staff member that promotes safety, supports recovery and sustains wellbeing. The model, created by the Carers Trust, is aimed at partnership working. The Trust is nearing completion of the first stage of this multi year plan. This involved services completing a self assessment tool, creating an action plan for areas requiring development. The Trust Executive hear regular updates on its progress as we are committed to significant cultural change in how we engage and support carers. Chair: Gary E Page Op . ‘i : “ Chief Executive: Michae! Scott 3 VV MINDFUL Trust Headquarters: Hellesdon Hospital, stonewall > EMPLOYER Drayton High Road, Norwich, NR6 5BE IIVIRSITY CHAMPION Tel: 01603 421421 Fax: 01603 421440 www.nsft.nhs.uk Ms Lake -2- 2. Although seen regularly by the Crisis Team, Mrs Mayer was seen by a number of different people as a result of which no trusting relationship could be established. She had to repeat her history at each visit to a different person about personal matters. The Crisis Resolution and Home Treatment (CRHT) team provide a 24 hour service, assessing and supporting service users with intensive treatment for defined periods of time. It has a team of fifty staff supporting a significant number of people across a large geographical area. These factors mean that planning and coordinating consistent staff contact with a service user is a challenge. The Trust recognises the impact this can have for service users and their carers, especially during times of crisis. The Trust is planning to review the functions of the CRHT over the forthcoming months. Included within this review will be how we can improve the consistency of staff engaged with the service user. | would like to provide you with an update on progress in early September. 3. Different treatments were offered to Mrs Mayer without the reasoning or their efficacy being discussed. This is recognised to be important because it is difficult to make informed decisions if the individual is not in receipt of all the required information. The Trust supports the best practice of informed decision making and is sorry this was not evident for Mrs Mayer. This is an area of practice which has significance across the Trust. The Trust will be emphasising this aspect of practice through its structures for learning, such as clinical forums and patient safety newsletter. 4. Mrs Mayer required help urgently on 14 November 2014 but due to an increase in demand no one was available to see her until 16 November 2014. It is understood Doctors are now called out and an on call manager can be contacted in such situations. This was a coniributory factor in the events leading to Mrs Mayer's death. The Trust is sorry that significant demand for the CRHT team meant they could not visit Mrs Mayer until late on Saturday 15 November 2014. As Mrs Mayer was going to sleep it was appropriate to agree to defer the visit until the next day. Mrs Mayer died during the night. The Trust is experiencing increasing demands for all of its services at a time of being challenged to make savings. It is recognised that when services such as the CRHT team reach levels of capacity there has to be robust mechanisms for escalation and contingency. To this end the localities across the Trust are reviewing their escalation plans for services such as CRHT and the Dementia Intensive Support Teams, both of which are required to respond to incoming referrals. Thank you for raising these matters of concern, as they align with the Trust's desire to take all available learning from this tragic event. " | propose to write again in September with an update of the CRHT review and contingency plans but if | can be of any further assistance please do not hesitate to contact me. Yours sincerely Michael Scott Chief Executive Chair: Gary E Page & Boy, oes Chief Executive: Michael Scott Vi A MINDFUL Trust Headquarters: Hellesdon Hospital, Stonewall a MPLOYER Drayton High Road, Norwich, NR6 5BE DIVERSITY CHAMPION 2s aev® Tel: 01603 421421 Fax: 01603 421440 www.nsft.nhs.uk
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