Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0438, written 16 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Nov 2015 |
|---|---|
| Reference | 2015-0438 |
| Deceased | Emma Bray |
| Coroner | Laura Johnson |
| Coroner area | East London |
| Category | Community health care and emergency services related deaths |
| 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 (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. F Head of Serious Incidents and Complaints, The Policy and
Patient Safety Directorate, Suite 12, Phoenix House, Christopher Martin
Road, Basildon, Essex, $$14 3EZ
1 CORONER
lam Laura Johnson, Assistant Coroner, for the coroner area of East London
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.
[HYPERLINKS]
3 | INVESTIGATION and INQUEST
On 25 February 2015 | commenced an investigation into the death of EMMA LOUISE
BRAY age 25 years. The investigation concluded at the end of the inquest on 26
October 2015. The conclusion of the inquest was the medical cause of death ofa
hanging and the conclusion that Emma Bray killed herself, the requisite intention for
suicide not being found.
4 | CIRCUMSTANCES OF THE DEATH
Emma Bray (“EB”) had a history of problems with mood dating back to her teens. In
2009 she received treatment for an impulsive overdose whilst under the influence of
alcohol following a relationship breakdown. She had some contact with mental health
services in 2011 and 2013. Towards the end of 2014 EB’s mood declined. She had
suffered a relationship breakup. Her mood became worse after Christmas.
On 6 January 2015 EB was assessed by the Waltham Forest Access and Assessment
Team Intake Team ("IT"). She gave details of her history and symptoms and told the
social worker that she was on medication prescribed privately. She also told the social
worker she was in the process of changing GP surgery. The social worker discussed
the case with a psychiatrist in the team and a decision was made to change the anti-
depressant medication from Ecitalopram to Sertraline. This recommendation was faxed
to the GP. The plan concluded “Emma to be considered for a brief allocation to monitor
response to medication.” A risk assessment was completed and recorded the risk of
self-harm as low.
The IT did not take steps to obtain EB’s full medication history either from her or from
her treating clinicians. No follow up telephone call or meeting was arranged. The
referral to the Brief Intervention Team (“BIT”) was not made, apparently because of
workload.
EB’s parents then had contact with the IT on 19 January 2015 by telephone when some
deterioration in her condition was reported. It was recorded that she would be discussed
in the Intake meeting the following day but this did not occur.
EB’s parents contacted the IT again on 22 January 2015 reporting that EB had no hope
she would get better and was pleading with them to end her life. When asked, the
parents reported no known concrete plans to self-harm. This information was not placed
before the IT MDT or passed on to anyone.
On 2 February 2015 EB’s mother contacted the IT again. More details were obtained
about EB’s medication history and the social worker said that an appointment with a
psychiatrist needed to be arranged. In the meantime the psychiatrist recommended that
the dose of Sertraline be increased from 50mg to 100mg. ,
On 11 February 2015 EB was seen at home by the social worker and psychiatrist. Her
parents reported concerns she would kill herself. They reported that she had been
researching suicide on the internet but said she was not brave enough to do it. Her risk
assessment was updated and the risk of self harm was increased to moderate. The
Sertraline was changed from night to morning and the psychiatrist recorded different
drug therapies he wished to consider. The plan was for a doctor’s appointment to
review the medication ASAP, for there to be a referral to the psychology panel and for
there to be a referral to BIT. The psychology panel referral was made, although the
panel that was due to sit on 16 February 2015 was cancelled and EB’s case was
delayed to the following week. Neither the doctor's appointment nor the BIT referral
were made.
In the morning of 19 February 2015 EB’s father emailed the social worker with a list of
symptoms and concerns: “we are of course very concerned as she says she is not going
to live her life much longer like this. We also have concerns about her medication as
things seem to be getting worse as the increased dose gets into her system’. He
emailed again at 15.08 on the same day “please call me as per last message
met Emma lunchtime and she is completely withdrawn and unable to interact. | know
we have been needy but really must know what is happening and see Emma’s health
plan with dates.” These emails were not entered into EB’s notes or indeed ever
provided by WFAAT.
On the same day EB’s mother spoke to another member of the IT who spoke to the
psychiatrist. He recommended an increase in the dose of Sertraline to 150my and to
introduce Quetiapine.
In the early morning of 20 February 2015 EB’s father emailed the social worker again
informing her that EB had “gone down, down down to the nasty place.”
EB’s mother spoke with the social worker that morning and was told that they would
have to wait for the medication to take effect. The plan recorded was for the social
worker to refer to the BIT and tol for EET advice.
On 23 February 2015 EB was discussed by the psychology panel. On the same day the
social worker referred EB to the BIT.
On 25 February 2015 EB hanged herself.
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. —
During the evidence | was told that a number of things had not happened that ought to
have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or
private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist
following assessment, to be seen and assessed within 14 days.
ee 2 that there was an underestimate of the level and complexity of EB’s
condition.
(e) EB remained with the Intake team for the whole period of her contact with the
service. This appears to have occurred because of a failure to make a referral
rather than because of any positive decision to retain her within the team.
(f) | EB should have been referred to an appropriate service, probably initially the BIT.
This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should
have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the change in her
presentation, most notably on 19 January, 22 January and then from 19 February
2015 onwards. Nothing happened in response to these reports. The information
should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in
response to the information of 19 February 2015 at the latest, had a psychiatric
assessment.
(k) |The emails sent by EB’s family were not placed on her notes; accordingly other
members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been
communicated to EB and her family. Where the drug was recommended by a
psychiatrist who had not seen or assessed EB it was unclear where responsibility
for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment,
including the medical history.
(b) Absence of guidance about where that information should be obtained from: the
patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when
to refer out of intake to other services.
(d) Lack of clarity about what contact there should be between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with
the IT but there is reason for concern about them.
(f) | Alack of monitoring / auditing of the passage of patients through the service to
see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take
place.
(h) Alack of appreciation of the need to create a plan with timescales for further
treatment / referral to take place.
(i) | Alack of clear information about the circumstances in which it is appropriate for a
psychiatrist to make recommendations about the medication without a full medical
history.
(j) Alack of clear information about the circumstances in which it is appropriate for a
psychiatrist to make recommendations about the medication without seeing the
patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about
medication to the individual when the medication is recommended by the WFAAT
psychiatrist but prescribed by the GP. This was particularly the case with the
Sertraline prescribed to EB, which apparently does have specific associated risks
that must be warned of.
(I) | The lack of apparent process or procedure to ensure that emails sent to staff
directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm.
The risk assessment tool in use appeared very basic and not one that provided
any real assistance to staff.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR 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 4" January 2016 |, 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 se; to the Chief Coroner and to the following Interested
Persons, land to the CQC.
lam 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] 16" November 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.
NeLeT WO Best care by the best people NHS Foundation Trust Trust Head Office Goodmayes Hospital 157 Barley Lane Goodmayes 1G3 8XJ Tel: 0300 555 1200 Ext:7228 RECE IVED Walthamstow Coroner’s Court Queens Road Walthamstow E17 80P 12" of January 2016 RE: NELFT’s Response to Prevention of Future Deaths Report | write in response to the Prevention of Future Deaths Report issued to NELFT on the 16" November 2016, following the Coroner's inquest into the death of Emma Bray. NELFT have developed an action plan in response to your recommendations and findings which is enclosed herein. We believe the plan comprehensively addresses the issues you have raised and builds on the existing action plan which was formulated from the internal NELFT investigation. The plan has five broad objectives within which your specific concerns have been addressed. These are: 1. Improve the quality of assessment and treatment plans 2. Improve communication with carers 3. Review and implement the Standard Operational Procedures in AABIT 4. Improve the standard of record keeping in AABIT 5. Ensure AABIT staff are competent in Risk Assessment and escalation of risk Please do not hesitate to contact us if your feel the action plan is insufficient in any way or if you require any clarification. Thank you for your helpful insights into this case. NELFT strives to learn from incidents and to constantly improve the service provision it provides. Yours sincerely TVGi0 Rows fF Executive Integrated Care Director (London) & Corporate Communications * P| www.nelft.nhs.uk Chief executive: John Brouder Personal Fai Diverse cHAUrIoN
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