Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0098, written 8 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Mar 2016 |
|---|---|
| Reference | 2016-0098 |
| Deceased | Elsie Tindle |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Cumbria, Northumberland, Tyne and Wear 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.
Derek Winter DL Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - The Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London SWI1A 2NS CORONER I am Derek Winter, Senior Coroner for the City of Sunderland. CORONER’S LEGAL POWERS I 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. http:/ http ww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 14" April 2015 I commenced an Investigation into the death of Elsie Tindle, aged 71 years. The investigation concluded at the end of the Inquest on 3" March 2016. The conclusion of the Jury Inquest was that she died ‘as a result of a rare complication following the lawful and necessary administration of ECT’. CIRCUMSTANCES OF THE DEATH Elsie Tindle had a complex personal and medical history. Miss Tindle was particularly close to her sister with whom she had lived. Miss Tindle had a psychiatric diagnosis of Depressive Disorder of a severe degree with a suspected underlying cognitive impairment and a learning disability. On 23" February 2015 Miss Tindle was made subject to section 3 of the Mental Health Act 1983 (MHA). Miss Tindle received Electro Convulsive Therapy (ECT) on 27" February 2015, 6" March 2015 and 9" March 2015. On 23" February 2015, a paper request for a Second Opinion Appointed Doctor (a SOAD) was made to the Care Quality Commission (CQC) and then subsequently online to the CQC, who acknowledged it the following day. Civic Centre, Burdon Road,Sunderland, SR2 7DN Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland www.sunderland.gov.uk/coroner It appears that no SOAD was ever allocated and that the request was not followed up. Miss Tindle had 3 sessions of ECT over an 11 day period as it was believed that the s62 MHA criteria had been made out in that it was immediately necessary to save the patient’s life or prevent a serious deterioration in her condition. Miss Tindle was removed from the section 3 on 11" March 2015. Miss Tindle developed focal seizures and status epilepticus, which required her transfer to the High Dependency Unit of Sunderland Royal Hospital, and she was then discharged back to the ward at the Hospital on 16" March 2015. On 19" March 2015 Miss Tindle was made subject to a Deprivation of Liberty Safeguard. By 29" March 2015 Miss Tindle appeared to develop aspiration pneumonia and, although she was treated with antibiotics, her decline continued and she died on 4" April 2015. Post-Mortem Examination on 14"" April 2015 gave the cause of death for Miss Tindle as: la Anoxic-Ischaemic Brain Damage Due to 1b Status Epilepticus Due to 1c Electro-Convulsive Therapy 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) [heard evidence that the present compliment of SOADs is approximately 105 and that in 2014/15 they carried out 14,373 visits. 25% of cases with a SOAD led to changes in a treatment plan and in 3% of cases the SOAD did not approve the plan. The SOAD safeguard in theory can prevent the inappropriate use of ECT. (2) For ECT, SOADs attend within 5 days in 82% of cases but I am concerned that in 1:5 cases this does not happen. (3) Practitioners anticipate delays with the appointment of SOADs and it is common to use the urgent powers under s62 MHA (it is immediately necessary to save the patient’s life or prevent a serious deterioration in their condition). (4) Lam concerned that there is a danger of the use of s62 MHA becoming a default position and that the numbers of SOADs may be insufficient to deal with matters in a more timely way. (5) I was encouraged to hear that each of the agencies had reviewed practices and procedures, particularly Northumberland Tyne and Wear NHS Foundation Trust, who were to set up a system for the treating Psychiatrist to chase the CQC in the absence of a timely appointment of a SOAD. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 5th May 2016. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - e Sunderland City Council and their Solicitors ¢ Northumberland Tyne and Wear NHS Foundation Trust by their Counsel and Solicitors e Care Quality Commission e Official Solicitor e Sunderland Royal Hospital I 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. Dated this 8" day.of March 2016 = Signature Lt Senior Coroner for the City of Sunderland
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.
Bs a Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whitehall Senior Coroner anon Civic Centre Tel: 020 7210 4850 Burdon Road Sunderland SR2 7DN 09 MAY 2016 Qe. Mie Vales i Thank you for your letter of 8 March 2016, following the inquest into the death of Elsie Tindle. I was sorry to hear of her death and wish to extend my condolences to her family. The main concerns arising from this case are: e that the Care Quality Commission’s (CQC) internal target for provision of SOADs is not met in all circumstances and the impact this has on safeguarding against inappropriate treatment; e that there is an insufficient number of Second Opinion Appointed Doctors (SOADs) to deal with requests for attendance in a timely way; e that the use of section 62 of the Mental Health Act (MHA) is becoming a default position. My officials have liaised with CQC about your concerns. Firstly, with regard to CQC’s lack of response to the request for a SOAD in this case, I have been advised by CQC that this was due to an administrative error. CQC has confirmed that a second opinion request was submitted by Northumberland Tyne and Wear NHS Foundation Trust and received by CQC. Although the request was processed, there was a failure to action it any further by transferring it from the submission system onto the allocation database, which is currently a manual process. Investigation of this error has led to two possible causes: e The task completed line was ticked in error. e There was an error on the submission and the request was misplaced before the query was resolved and the process completed. CQC has undertaken a 100% comparison check between the submission database and the allocation database and has confirmed that this was an isolated incident. However, they have taken the following actions to mitigate against further error: e The team have been reminded of the process for recording actions taken against requests received; e Daily 100% comparison checks are now carried out by the team leader. Any requests submitted with queries are entered onto the allocation database with a status of pending. The team leader keeps checking the progress of pending second opinion requests until all issues are resolved; e An electronic solution to enable automatic transfer of request to the allocation database is in the final stage of roll out. This will reduce the risk of human error in future. You are also concerned that CQC do not always meet their internal target for provision of SOADs. Whilst CQC fully endeavour to meet these targets, there are several factors that can affect their ability to do so. Requests for Second Opinions are demand led. CQC has no control over when and where a request will be required or the level of urgency required for each case. In addition, as most SOADS are in full or part time employment with provider organisations, it can be difficult to identify a local, available SOAD who can attend promptly. As a second treatment of the patient is often carried out within 48 hours of the request being submitted it makes timely attendance of a SOAD even more challenging. Missing or inaccurate request information submitted by the provider can add in further delay. In addition, providers do not always make appropriate arrangements to enable the SOAD to attend the ward, interview the patient and have access to the statutory consultees either in person or at least via telephone, so that a certificate can be issued. Another problem, although less common, is when a SOAD is unable to access a ward due to protected times. To turn to your concern about the available number of SOADs, CQC has an ongoing recruitment campaign and invites expressions of interest from prospective applicants. Their recruitment process is supported by HR colleagues and the Lead SOAD. CQC will continue to recruit more Consultants as SOADS but because the work is so demand led, a model of continuous availability is not considered feasible. It is also essential to continue to ensure that the SOAD is independent of the provider and other parties. we Department of Health CQC continues to work with the Royal College of Psychiatrists to promote the value of the SOAD role and its importance to the provision of comprehensive mental healthcare. They are also considering other ways of promoting the SOAD role including reviewing the current fee structure and are looking at providing some aspects of the service in a different way that could free up more SOAD time. Lastly, I will address your concern that the use of s62 of the MHA is becoming a default position. S62 of the MHA provides provision to urgently treat a person who has been detained under the MHA. Sometimes, decisions have to be taken rapidly to detain and then treat a deteriorating patient and this should be clearly understood by the s62 provision of the Act. CQC has raised concerns about the use of s62, (separate from the issue of SOAD availability), which they highlighted in their MHA Monitoring Annual Report for 2013/14. They are concerned that these measures are being used in situations that are neither urgent nor emergency. They also perceive that there are occasions when s62 may be used, whether for medication or for ECT, for the purpose of clinical convenience rather than a situation of immediate necessity. As a consequence of these concerns the 2015 MHA Code of Practice has been strengthened to state that hospital managers should monitor both the use of urgent treatments and exceptions to the certificate requirements, to make sure that they are not used inappropriately or excessively. CQC also expect providers to make sure that treatments given on this basis are reviewed regularly. Clinicians must specify review periods at the point that the urgent or emergency treatment is instigated. CQC Inspectors and Mental Health Act Reviewers continue to look at compliance with the MHA Code of Practice during inspections and MHA monitoring visits. In addition SOADs have been instructed to feedback any issues regarding the use of s62 which they may encounter on their visits, directly to CQC, so that targeted intervention can be addressed to relevant providers as necessary. I hope that this reply is helpful and I am grateful to you for bringing the circumstances. of Ms Tindle’s death to my attention. Num fencanky My G2 ALISTAIR BURT
See every Prevention of Future Deaths report matching Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.