Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0239, written 24 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jun 2015 |
|---|---|
| Reference | 2015-0239 |
| Deceased | Alice Mead |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Suicide (from 2015) |
| Organisation named | Sussex Partnership 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.
? VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner THE CORONER’S OFFICE WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON BN2 3QB Assistant Coroners (s (a s Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONERS SOCIETY OF ENGLAND AND WALES 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. Mr. Colm Donaghy, Chief Executive, Sussex Partnership NHS Foundation Trust 2. EE | egal Support Manager, Sussex Parternship NHS Foundation Trust CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 26" May 2015 | commenced an investigation into the death of Alice MEAD. The investigation concluded at the end of the inquest on26th May 2015. The conclusion of the inquest was SHE TOOK HER OWN LIFE 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest (attached) VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 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. Alice was known to the Mental Health Services, both as an inpatient and as needing care from community services. She was looked after using the Care Programme Approach. | Three serious failings in her care were identified at her Inquest. It was not possible to say that they were directly contributory to her death at the time (i.e. on the 20" January 2015) but, they have raised sufficient concern with me. The MATTERS OF CONCERN are as follows (1) When her Care Co-ordinator left the Trust she was not. replaced so Alice was left without one of the corner stones of the Care Programme Approach. Although later a Multi-Disciplinary Team meeting decided she should have a Care Co-ordinator, no action was taken to appoint one. (2) In spite of Alice calling the Brighton Urgent Response Service twice in December 2014. asking for a medication review and explaining she was not taking her mental health medications, no action was taken to keep her informed of discussions within the Mental Health Service. In particular her request for a medical review was discussed with her Consultant Psychiatrist and he apparently took the view that it was not necessary (poorly documented). Since there was no discussion with Alice, from her point of view, there was a lacuna in her care at a time when she was especially vulnerable, which lasted for several weeks. (3) Action, if it can be described as action, was only taken when Alice’s young son's Heath Visitor wrote of her urgent concerns about Alice in good detailed e-mails sent to Alice's GP and to the Community Mental Health Team on the evening of the 15" January. It was clear that the Mental Health Team should react. Their | response was to phone Alice on the 16'" and make an appointment to see her on the 28" January. This “hands off’ approach to a known vulnerable patient is unacceptable. The patient should be at the heart of Care Programme Approach care (indeed any care). VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 (4) There was no evidence that Alice’s risk assessment was reviewed and updated during December 2014 or January 2015. If it was, such reviews should have been documented in accordance with the Care Programme Approach. They were not ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND your organisation 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 11" September 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 Persons hz! . Secretary of State for Health, Department of Health — Chief Executive NHS England ational Patient Safety Agency - ER Health visitor | have also sent it to:- 1. RE oirector of Public Health, Brighton & Hove Clinical Commissioning Group 2. ees of Clinical Quality and Primary Care, Brighton & ove Clinical Commissioning Group Who may find it useful or of interest. OrhRwn-a VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 30B Assistant Coroners Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 | 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: 24" June 2015 SIGNED BY: Senior Coroner Brighton and Hove —
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.
A member of: Sussex Partnership Association of UK University Hospitals NHS Foundation Trust Our Ref: CD/cda D | 25 August 2015 | i Swandean Miss Veronica Hamilton-Deeley LLB i Aun orneg Her Majesty’s Senior Coroner for the bow 2 on West Sussex City of Brighton & Hove BN13 3EP The Coroner's Office Woodvale, Lewes Road Tel: 01803 843033 Dear Miss Hamilton-Deeley Re: The Late Alice Mead Thank you for your report of 24 June 2015, written pursuant to the Coroners & Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and for highlighting the matters giving rise to concern. Our thoughts are with Ms Mead’s family and friends and we would like to reiterate our condolences on their tragic loss. Following Ms Mead’s death, a serious incident investigation was conducted and following the inquest, John Child, Service Director - Brighton & Hove, convened a meeting with both managerial and clinical colleagues in his service who were directly involved in Ms Mead’s care, to discuss the learning and actions arising. This letter summarises the learning and | hope it provides assurance that the matters you have raised have been taken seriously and improvements in Sussex Partnership have been made to continually improve the care we provide to our service users and their families. As you say, a care coordinator was not allocated to Ms Mead when her previous care coordinator left the Trust. At that time, Ms Mead’s case was reviewed, and the decision was made not to allocate a new care coordinator. [J General Manager, Community Services Brighton & Hove, has confirmed the introduction of an improved system; where, all care coordinators’ caseloads are reviewed with a Consultant Psychiatrist and Team Leader. Particular focus is applied to caseload reviews when a care coordinator is leaving and the decisions and outcomes are documented by the reviewing team on the electronic health record clinical information system. Service users will-be allocated a lead practitioner or care coordinator, based on their clinical need and are not reliant on calling the duty team. There is a rolling programme of case load reviews for all clinical community staff and the review team consists of a Consultant Psychiatrist, the team leader and clinical supervisor as a minimum. The Care Programme Approach (CPA) is in the process of being reviewed across the Trust. This work is being led Director of Occupational Therapy and Recovery Practice. We have a newly constituted CPA steering group, with cross care group representation and we are agreeing the new processes in preparation for the roll out of Carenotes (the new electronic records system). A new CPA policy has been drafted and we hope to launch it in September 2015. When the new CPA policy is launched there will be full staff training in place. Information leaflets and short films will be available and all information will be available on the Trust's intranet. The training will be co-produced with service users and peer trainers to ensure a holistic approach. We are also developing .practice guidance to help staff to think about how to plan care more sensitively in consultation with the service user. This work is quality focussed and will provide greater clarity for staff and their roles within CPA. Chair: Caroline Armitage Chief Executive: Colm Donaghy Trust Headquarters: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP www.sussexpartnership.nhs.uk A Teaching Trust of Brighton and Sussex Medical School In relation to the calls Ms Mead made and communication with staff, Brighton Urgent Response Service, now Mental Health Rapid Response Service (MHRRS), and the Assessment and Treatment Service (ATS) Duty Team are now co-located in the same working space. They have agreed a protocol for information sharing. This allows for improved communication between the teams and for vital information on service users to be shared with staff and fed back to service users. There is a communication book in place and a whiteboard to keep key pieces of information and service user contacts prominent within the team. In addition, to aid improved communication, there is now a Duty Lead working every day. The Duty Lead working that day prioritises the incoming work and supports the decisions made by the call takers. They review and update the communication book and whiteboard. The Team Leaders go in to provide extra support and they have reiterated to their staff the importance of good communication and documeniation. Within the local leadership team it has been agreed to form three clusters that will cover a set group of GP surgeries. Once fully established this will allow the team to work more closely together and provide each with greater support. Staff in the East ATS and MHRRS, responsible for assessing service users’ risk, have undergone bespoke Applied Suicide Intervention Skills Training (ASIST). This internationally renowned training was delivered in June 2015 by Grassroots, Suicide Prevention charity. To ensure risk assessments are up to date we have developed a new East ATS caseload spread sheet to capture tisk assessment dates; supervisors will monitor this frequently, audit compliance, and escalate to the Team Leaders if action is required. Following Ms Mead’s inquest, a new approach to calls is underway in East ATS. If a service user calls 3 times in a 2 week period in need of mental health input, they will be seen face to face. The only exceptions will be in circumstances when the case is reviewed by a senior member of the team and a face to face appointment is not deemed in the best interests of the service user or appropriate; in these cases a detailed record will be kept documeniing the decision rationale. There are local monthly leadership meetings, chaired by Fiona Blair, ATS Service Manager, Brighton & Hove Locality. Fiona has shared the learning from Ms Mead’s inquest (anonymously) at the Leadership Meeting. As a Trust we are committed to learning and improving patient safety. Lessons from Ms Mead’s experience were shared through the Trust's Report and Learn Bulletin and via the Trust’s Quality and Safety Report, distributed throughout the Trust and with the CCGs. Thank you again for your report. The Trust has no objections to this letter being shared or published by the Chief Coroner. Yours sincerely Colm Donaghy Chief Executive
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