Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0131, written 9 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 | 9 Mar 2016 |
|---|---|
| Reference | 2016-0131 |
| Deceased | William Higgleton |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Community health care and emergency services related deaths |
| Organisation named | North East London 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:
1. John Brouder, Chief Executive, North East London Foundation Trust,
Goodmayes Hospital, Barley Lane, Goodmayes, Ilford, Essex, IG3 8XJ
2. an Chief Officer, Redbridge CCG, Becketts House, 2-14 Ilford,
Ilford, Essex IG1 2QX
1 | CORONER
| am Nadia Persaud, Senior 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.
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made
3 | INVESTIGATION and INQUEST
On the 28" July 2015, | commenced an investigation into the death of William Stanley
Higgleton. The investigation concluded at the end of the Inquest on the 1 March 2016.
The conclusion of the Inquest was a narrative conclusion:
Mr Higgleton suffered anti-social personality disorder and mixed anxiety and depressive
disorder. He had reported multiple overdoses in the period November 2013 to March
2015. He was assessed as high risk to self from November 2013 to July 2015. Despite
the history of overdoses and the considered high risk to self, his access to medication
was not limited. He did not have any support in the community from the mental health
team, to assist him with compliance with medication or to assess his mental state more
frequently and in his home environment. On the 2ar4 July 2015 he was found deceased
in his home address. Mr Higgleton had taken his own life by ingesting excessing
amounts of medication. He had taken his own life while suffering from a mental disorder.
4 | CIRCUMSTANCES OF THE DEATH
Mr Higgleton had suffered from anti-social personality disorder for many years. He had
also suffered from anxiety and depressive disorder for around 5 years prior to his death.
He came under the care of the North East London Foundation Trust from November
2013. He was referred to the mental health team at this time, as he had taken an
overdose of medication. Mr Higgleton had been seen > a June 2014. Hi
WM considered the diagnosis to be mixed affective disorder Z—EEEEthen saw
him in October 2014, March 2015 and July 2015 iil considered the diagnosis
to be anti-social personality disorder and mixed anxiety and depressive disorder.
HE onfirmed that Mr Higgleton had complex needs. She did not however
consider that he would fit the criteria for CPA or the Community Recovery Team. Mr
Higgleton remained under the HAABIT team for 20 months, despite HAABIT being a
short-term assessment team
QE confirmed that throughout her period of caring for Mr Higgleton, he was
considered as a long term high risk of harm to self. He had a history of taking overdoses
and self-harming by cutting. He also reported in March 2015 taking monthly overdoses
with suicidal intent.
confirmed that the high risk presented by Mr Higgleton had been managed
through psychiatric assessments (planned every 2-3 months), prescription of anti-
depressive and anti-psychotic medication and by referral to psychotherapy services.
During the period of the care under NELFT, Mr Higgleton had not received any
psychological therapies.
On the 22™ July 2015 Mr Higgleton was found deceased in his bed at home. There is no
evidence of any third party involvement in his death and no suspicious circumstances.
The toxicology revealed excessive amounts of Citalopram, Tramadol and Mirtazapine in
his blood. The pathologist gave a cause of death of 1a multiple drug overdose.
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. —
WR considered that Mr Higgleton’s primary diagnosis was anti-social personality
disorder. She confirmed that the primary treatment for this condition would be
psychotherapy serdoce MMII ccetiraed however that there is a lack of service
provision for psychotherapy care to be provided to persons suffering from anti-social
ersonality disorder. The lack of service provision in this regard was confirmed oy
ee] (Assistant Director Adult Mental Health and Learning Disabilities).
| consider that the lack of provision of psychotherapy services to this group of patients
presents a risk of future deaths occurring.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | 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 4 May 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 si ‘o the Chief Coroner and to the following interested
—_ ae of the deceased). | am also forwarding a copy to
report to the Care Quality Commission and toi (Director of Public
Health) 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.
Z\
[DATE] =F. 3.16 [SIGNED BY CORONER] LY {\ \nm
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.
Best care by the best people NELFT NHS Foundation Trust | PRIVATE & CONFIDENTIAL \ Trust Head Office Ms Nadia Persaud Goodmayes Hospital Senior Coroner Barley Lane Walthamstow Coroners Court \lford 1G3 8XJ Queens Road Walthamstow Tel: 0300 555 1298 28 April 2016 Dear Ms Persaud, Re: Inquest touching upon the death of Mr William Stanley Higgleton , Regulation 28 Report | write in response to the Prevention of Future Deaths Report issued to North East London NHS Foundation Trust and Redbridge Clinical Commissioning Group on the 7" March 2016, following the Coroner’s inquest into the death of Mr William Stanley Higgleton. Please note that the North East London NHS Foundation Trust (NELFT) and Barking and Dagenham, Havering, Redbridge Clinical Commissioning Groups (CCGs) met on 30" March 2016 and discussed the Coroner’s concerns set out in the Regulation 28 report relating to the death of William Stanley Higgleton. At the meeting, an agreement was reached to review the care pathways for the patients suffering with anti-social personality disorder, to ensure that they are supported to access the existing services in conjunction with National Institute for Health and Social Care Excellence (NICE) guidelines. It was also agreed that communication plan will be developed to ensure that the staff involved in provision of care of these patients are aware of the pathways they should follow. This review will also indicate if there are any gaps in the existing provision of services, so that the appropriate action could be taken for the purposes of compliance with NICE guidelines. We will also consider how we could develop personality disorder networks locally as per NICE guidance. The review should commence in May 2016 with the view of completing it by 30 September 2016. Please find attached report for the Coroner, which was prepared jointly by NELFT and CCG following the meeting on 30" March 2016. NELFT strives to learn from incidents and to constantly improve the service provision it provides. Please do not hesitate to contact me if you require any clarification. Thank you for your helpful insights into this case. Yours sincerely, John Brouder Chief Executive www.nelft.nhs.uk Chair: Joe Fielder Chief Executive: John Brouder Conor Burke Chief Officer BHR CCGs
See every Prevention of Future Deaths report matching North East London 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.