Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0276, written 14 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jul 2015 |
|---|---|
| Reference | 2015-0276 |
| Deceased | Emma Carpenter |
| Coroner | Stephanie Haskey |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Nottingham University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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 THIS REPORT IS BEING SENT TO: 1. The Department of Health 2. The Department for Education 3. NHS England 1 | CORONER lam Miss Stephanie Haskey, Assistant Coroner, for the Coroner area of Nottinghamshire 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 In November 2014 an Inquest into the death of Emma Carpenter was opened, and it was resumed on 22" June 201 5, concluding on 13" July 2013. A Narrative Conclusion was recorded as follows: “Emma Charlotte Victoria Carpenter died at The Queen's Medical Centre Nottingham as a result of Multi Organ Failure caused by severe Anorexia Nervosa. Her death was contributed to by delay in accessing effective inpatient treatment and physical health monitoring prior to September 2005”. 4 | CIRCUMSTANCES OF THE DEATH : . Miss Carpenter was treated as an outpatient at the Child and Adolescent Mental Health Services Thorneywood Unit of the Nottinghamshire Healthcare NHS Trust (‘the Trust”) from February 2004 to November 2006, during which time she was a pupil at the Nottingham Girls’ High School and in the care of her Mother, and later her Maternal Grandparents. During this time there were significant gaps in communication concerning the severity of her condition which affected all of the above. By the time she was admitted as an inpatient on 27"" November 2006 she was too ill to survive and therefore died on 22™ December 2006. Whilst Miss Carpenter was an outpatient, and whilst she was an inpatient, there was no Trust specialist Eating Disorder Service for Children and Adolescents to which she could have been referred. 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. Although the Trust has now set up a specialist Eating Disorder Service for children and adolescents, there is only short term funding in place for this” service and a lack of commitment from Commissioners for its long term future. 2. There remains still a national lack of provision of inpatient beds for mentally ill children and adolescents including those who suffer from eating disorders. 3. Although the view of mental health professionals was that it was important for school nurses to attend Multi Disciplinary Meetings to understand and assist with care planning, this does not happen on a regular, reliable basis due to lack of funding for school nurses. 4. Inthe absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisations have the power to take such action. | have addressed this report to all three organisations, as | trust that all three will wish to consider together how the issues arising from this Inquest may be addressed and how cases such as Miss Carpenter's may best be managed in future. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8" September 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Nottinghamshire Healthcare NHS Trust Nottingham University Hospitals NHS Trust Nottingham High Schoo! for Girls Nottingham Safeguarding Children Board The Care Quality Commission. ! have also sent copies to Ofsted, the Independent Schools Inspectorate and the School Inspection Service, who may find it useful or of interest. | 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], - [SIGNED BY Co ae Mee FAS Stephanie Haskey A y a bt
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. The Chief Executive, Doncaster and Bassetlaw Hospitals NHS Foundation Trust 41 | CORONER lam Miss Stephanie Haskey, Assistant Coroner, for the Coroner area of Nottinghamshire 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 In November 2014 an Inquest into the death of Emma Carpenter was opened, and it was resumed on 22™ June 2015, concluding on 13"° July 2013. A Narrative Conclusion was recorded as follows: “Emma Charlotte Victoria Carpenter died at The Queen’s Medical Centre Nottingham as a result of Multi Organ Failure caused by severe Anorexia Nervosa. Her death was contributed to by delay in accessing effective inpatient treatment and physical health monitoring prior to September 2005". 4 | CIRCUMSTANCES OF THE DEATH Miss Carpenter was treated as an outpatient at the Child and Adolescent Mental Health Services Thorneywood Unit of the Nottinghamshire Healthcare NHS Trust (“the Trust”) from February 2004 to November 2006. During this time there was insufficient monitoring of her physical health, and in particular no specialist input by paediatricians or physicians. 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. The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen’s Medical Centre, there are no equivalent links with Bassetlaw Hospital. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisations 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 8 September 2015 |, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, seiting 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: Nottinghamshire Healthcare NHS Trust Nottingham University Hospitals NHS Trust — High School for Girls Nottingham Safeguarding Children Board The Care Quality Commission. | 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. ra DATE [SIGNED BY CORONE J on lk Ee Stephanie Haskey °
3 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.
ase, From George Fi reeman MP fs Minister for Life Sciences | Department Freeman.MPST@bis. gsi.gov.uk ; Department for Business os of Health Innovation & Skills Miss Stephanie Haskey HM Assistant Coroner — Nottinghamshire ; The Council House SJ Old Market Square Nottingham NGI 2DT 13 August 2015 Miss Haskey, Thank you for your letter to Secretary of State about the death of Emma Carpenter. I was saddened to read of Emma’s death. Please pass my condolences to her family and loved ones. Your report detailed the treatment received by Emma over the course of her illness, culminating in her death in November 2006. Some of the concerns you noted in Emma’s case were: e A lack of inpatient bed provision for mentally ill children and adolescents (including those suffering eating disorders) e Lack of funding for school nurses (although it is important for them to attend Multi-disciplinary meetings). e In the absence of school nurses, there are no clear connections between mental health professionals and the education system. On the issue of in-patient bed provision, DH provided NHS England with £7million in 2014/15 in response to an NHS England Tier 4 Report, published in July 2014. This funding was to provide: around 50 extra Children and Adolescents Mental Health Service (CAMHS) Tier 4 beds for young patients in the areas with the least provision (South West and Yorkshire). Also additional case managers, new standardised access protocols throughout the country, and a new case management system to make the best use of existing resources. More than 60 new beds have been commissioned, bringing the total to over 1,400 beds, the highest this has ever been. Out of these 232 are reserved for patients with eating disorders. Some general children and young people’s mental health units also treat eating disorders therefore the numbers are likely to be higher at varying times of the year. ‘Future in Mind’ (March 2015), in response to the work of the Children and Young People’s Mental Health and Emotional Wellbeing Taskforce established a clear and powerful consensus about change across the whole system to improve children and young people's mental health and wellbeing. The Government has confirmed its commitment to take forward the ambition set out in Future in Mind and we are making progress, including: 1. NHS England has distributed £30m of funding this year, specifically to improve eating disorder services. NHS England and the National Collaborating Centre for Mental Health published on 3 August 2015, a commissioning guide for clinical commissioning groups (CCG)s which sets out how to prepare for the access and waiting time standard for Children and Young People with an Eating Disorder ready for implementation from 2017. 2. The sooner someone with an eating disorder starts an evidence-based NICE- concordant treatment the better the outcome. The standard is for treatment to be received within a maximum of 4 weeks from first contact with a designated healthcare professional for routine cases and within 1 week for urgent cases. In cases of emergency, the eating disorder service should be contacted to provide support within 24 hours. We are working toward the majority of admissions meeting these standards. 3. On3 August 2015, NHS England published guidance, backed by additional investment, asking Clinical Commissioning Groups to continue and accelerate intensive work with local partners across the NHS, public health, children's services and education sectors to jointly develop and take forward local plans to transform the local offer to improve children and young people's health and wellbeing. Health Education England (HEE) was established to deliver a better healthcare workforce for England and is accountable for ensuring a secure workforce supply for the future. We have a responsibility for promoting high quality education and training that is responsive to the changing needs of patients and local communities and will work with stakeholders to influence training curricula as appropriate. In April 2014 Public Health England (PHE) and the Department of Health published guidance to commissioners for services to school aged children, Maximising the school nursing team contribution to the public health of school- aged children. At an England-wide level, during the 2014 planning round, NHS employers of school nurses indicated that they currently have some high levels of vacancies. | . Department | Department for Business | of Health innovation & Skills HEE’s Workforce Plan for England sets out our intention to commission 340 training places for school nurses in 2015-16, representing a 71.7% increase on last year, in order to support increased provider demand, all of whom will make important contributions to the health of the general population. HEE also intend to increase commissions for the four branches of nursing. Detail can be found in the table below. 2014/15 Planned 2015/16 . . % Increase commissions commissions Adult Nurses 13,228 13,783 4.2 Children’s Nurses 2,182 2,343 7.4 Learning Disabilities Nurses [653 664 7 Mental Health Nurses 3,143 3,243 B.2 Lastly, HEE plans to undertake a long term piece of work to review curriculums of all National Health Service commissioned training programmes to include recognised areas of health including learning disability, mental illness, physical illness and physical ill health and social support needs. HEE will work with regulatory bodies including the NMC to agree the standards and content for education and training, this is anticipated to be completed by April 2017. I hope that this information is useful. Thank you for bringing the circumstances of Emma’s death to our attention. Yours sincerely, ett OLS ° GEORGE FREEMAN
Doncaster and Bassetlaw Hospitals NHS Foundation Trust Sewa Singh, Medical Director PA: Tel: Email: 5 October 2015 Miss Stephanie Haskey Assistant Coroner HM Coroner’s Service The Council House Old Market Square Nottingham NG1 2DT Dear Miss Haskey Further to the Regulation 28 Report to Prevent Future Deaths (PFD) Letter, issued on 14 July 2015 following the inquest of Emma Carpenter, | would like to apologise for the delay in our response to you. While we had no involvement in this case, we have been requested through this PFD to engage with the Eating Disorder Service provided by Nottinghamshire Healthcare Trust. | wish to confirm that this Trust has communicated formally to Nottinghamshire Health Care Foundation Trust, to understand how we can support patients from the Bassetlaw area whilst receiving treatment in Thorneywood Adolescent Unit. We offered a formal service level agreement and a named consultant to be the link to the service. The response fon a Deputy Director Local Services Division at Nottinghamshire Healthcare Trust was: “Thank you for your letter of 20th July 2015 regarding the Regulation 28. Following our conversation, we cannot anticipate any regular requirement from Doncaster and Bassetlaw Hospitals NHS Foundation Trust to provide paediatric support at Thorneywood Adolescent Unit. | am sure it would be adequate to agree any paediatric advice on a case by case basis should this ever be required. Please do get back to me if you need anything else.” We have an identified Consultant and will actively engage with the services provided by Nottinghamshire Healthcare Trust as the need arises and will monitor these arrangements through the paediatric clinical governance team. As a Trust we are committed to improving our services and working actively with other provider organisations in the health community. Yours sincerely Singh MBChB MD FRCSEd Medical Director
England Bruce Keogh Medical Directorate 6° Floor, Skipton House 80 London Road H.M. Assistant Coroner for Nottinghamshire 4" September 2015 Miss Stephanie Haskey HM Coroner's Service The Council House Old Market Square Nottingham NG1 2DT Dear Miss Haskey, Re. Regulation 28 report ~ Emma Carpenter | am writing in response to your report under Regulation 28 regarding the very sad death of Emma Carpenter. Before | set out my response to the questions in your report | would like to express my deep sympathy to the Carpenter Family and sadness at the death of their daughter. | have set out below the actions that are being taken to improve the delivery of care for children and young people with an eating disorder, to support their families and carers, prevent poor long-term outcomes and the tragic death of a young person. ‘ 1. Long term investment for inpatient Child and Adolescent Mental Health Services (CAMHS) beds for those suffer from eating disorders Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifications that require acute inpatient mental health units (also known as CAMHS Tier 4 units) for children and young people to manage a range of mental illnesses including eating disorders. In addition, NHS England also commissions specialist inpatient eating disorder units across the country. Further to the additional beds already commissioned by NHS England, we are currently in the planning stage of a procurement process which will help to ensure that we commission inpatient beds according to need rather than based on history. Whilst it is our understanding that there were beds available at the time of this tragic death, NHS England also recognises the importance of appropriate community eating disorder services and gaps in this provision across the country. This is reflected in the recent report of the Children and Young People’s Mental Health Taskforce ‘Future in High quality care for all, now and for future generations Mind’ (http:/Avww.future-in-mind.co.uk/), jointly chaired by the Department of Health and NHS England. The Future in Mind report establishes a clear and powerful consensus about how to make it easier for children and young people to access high quality mental health care when they need it. It looks at whole system, multi-agency responses from early intervention to supporting children and young people with the most severe needs. 2. Current action to improve access to evidence based eating disorder treatment and continuity of care throughout a young person’s care path. NHS England is investing £30m per year for Clinical Commissioning Groups (CCG's) to develop and deliver evidence based community Eating Disorder services. This funding is in addition to resources already in place to deliver treatment for young people with eating disorders. In July 2015 NHS England published an access and waiting time standard and commissioning guidance on how the additional funds are to be used to commission evidence based community Eating Disorder services for children and young people (http://www. bing com/search?q=access+and+waiting+time+standard+for+children-tand+ oung+people+witht+an+eating+disorder&srcslE- TopResult&FORM=IE10TR&adit=strict). This is to support CCG’s preparation to meet a new standard for evidence based eating disorder treatment to be delivered within a maximum of 4 weeks from first contact for routine cases and 2 weeks for urgent cases. The first target for the standard is to be implemented from April 2017-18. The community eating disorder model of care sets out how evidence based advice, consultation and treatment is to be accessed easily by those who are concerned; this is to include self-referral for young people or concerned parents as well as school staff and GPs. The aim is to ensure that the broad and varying needs of a child or young person with an eating disorder, as well as the needs of their family or carer, are met as soon as need or concerns arise. In your report you highlight the ‘significant gaps in communication concerning the severity of her condition’ and how this contributed to the breakdown of care. The eating disorder guidance emphasises the role of community eating disorder services to provide oversight and support throughout a young person’s care path including times of admission to a paediatric ward or inpatient CAMHS unit. CCG’s are currently developing local plans for how they will enhance or develop community eating disorder services for children and young people and will be able to access funding from NHS England from September 2015. 3. Work to improve links and communication between CAMHS and schools and improve mental health awareness and knowledge among school staff Over the last few years there has been a range of initiatives to improve the understanding of school staff about mental health issues and to improve communication. These include: High quality care for all, now and for future generations « MindEd e-portal (https:/Avww.minded.org.uk/) which includes e-learning sessions specifically on eating disorders to improve mental health awareness and knowledge among school staff. e Department of Education's publication on Mental Health and Behaviour in Schools (httes:/Avww.gov.uk/government/publications/mental-health-and- behaviour-in-schools--2). * Public Health England’s guidance on Promoting Emotional Health and Wellbeing in Schools (hitps://www. gov. uk/government/publications/promoting-children-and- young-peoples-emotional-health-and-wellbeing). e NHS England are about to pilot an initiative with the Department for Education to develop a programme for single points of access in Tier 3 (specialist community) CAMHS and schools, testing it over at least 15 CCGs. The training will be for an identified member of staff from the NHS CAMHS team plus a member of the schoo! staff and additional colleagues such as, Special Educational Need Co- ordinators, school nurses and counsellors. This is linked to a recommendation from Future in Mind. The Spring Budget allocated £1.5 million to support this pilot over the next year from July 2015 to June 2016. NHS England is committed to improving children and young people’s mental health services across the whole care pathway no matter who is the responsible commissioner. This will include young persons with eating disorders. We hope that the above information addresses your concerns and that this provides reassurance that NHS England is taking not only immediate necessary action but investing in both inpatient and community provision that affects a young person's care pathway within mental health. Bruce Keogh KBE, MD, DSc, FRCS, FRCP National Medical Director NHS England High quality care for all, now and for future generations
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