Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0142, written 12 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Apr 2016 |
|---|---|
| Reference | 2016-0142 |
| Deceased | Dennis Bennett |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Greater Manchester West Mental Health 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: Chief Executive of Trafford Council and the Chief Executive of Greater Manchester West Mental Health NHS Foundation Trust CORONER Lam Joanne Kearsley Area Coroner for Manchester South 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 INVESTIGATION and INQUEST On the 5" April I concluded the Inquest into the death of Dennis Bennett date of birth 24.07.1939 who died on the 07.02.2016. The cause of death was 1a) Dementia I recorded a natural causes conclusion. CIRCUMSTANCES OF THE DEATH The Court heard evidence that the deceased had a history of dementia and on the 29" November 2015 was admitted in accordance with Section 2 Mental Health Act to the Moorside Unit under the care of Greater Manchester West Mental Health Trust. (GMW). The deceased was shortly after his admission transferred to Wythenshawe hospital for medical treatment before being returned to the Moorside Unit on the 6" January 2016. At this time he was admitted under Section 3 of the Mental Health Act for ongoing treatment for his mental health. The treatment plan was initially for him to be well enough to be discharged to nursing home care. However on the day of the nursing home assessment his condition deteriorated and he was no longer well enough to be discharged. By the 13" January he was for end stage palliative care and following a meeting with the family the plan was that he would remain on ward in the Moorside unit. On the 14” January the Consultant made an urgent Deprivation of Liberty Safeguarding Application to Trafford Council. As this was an urgent application the application commenced on the 14" January. At this time the deceased was in act still being detained under S3 of the Mental Act and this was not rescinded until the 15" January 2016. The urgent application expired on the 21* January 2016 at which time GMW contacted Trafford Council as the standard authorisation had not been considered. It was the understanding of GMW (albeit the witness from GMW who had responsibility for safeguarding in the Trust was in fact employed by Trafford Council) that the urgent application continued until the best interest assessments could take place and the deceased despite now being on end stage palliative care was subject of DOLS at the time he died. Another employee of Trafford Council provided evidence that when he was | asked for advice from the Trust the position of the Council was.that there was no DOLS in place following the expiration of the urgent authorisation until such | time as the standard application had been processed. j CORONER’S CONCERNS The concerns noted by the Court during the course of the Inquest are as follows: 1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act. 2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. 3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific. 4, The deceased was then on end stage palliative care and entirely compliant : with treatment there was little consideration as to why a DOLs was | applied for as opposed to treating the deceased in his best interests. | Whilst in this case the application did not impact on his care or treatment there is i aconcer that a lack of understanding and differing information may and could } impact on other patients. 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 ure 2016 I, the coroner, may extend the period. report, namely by 1 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 namely, the family of Mr Bennett. 1am 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. 12.04.2016 Joanne Kearsley Area Coroner [her
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.
H M Coroner Manchester South Chief Coroner's Office 148 Floor Tomas Moore Royal Court of Justice Strand London WC2A 2LL Dear Sirs RE: Dennis BENNETT (Deceased) 23 May 2016 Our ref: JK/HC/00331-2016 Please find attached a copy of the response to the Regulation 28 Report received from the Chief Executive of Greater Manchester West Mental Health NHS Foundation Trust. Yours faithfully / John $ Pollard LI.B. Hons, Senior Coroner Joanne Kearsley LI.B. Hons Grad.Dip Psych, Area Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Telephone: 0161 474 3993 Facsimile: 0161 474 3994 www.coronersmanchestersouth.org.uk Greater Manchester West Mental Health NHS Foundation Trust Trust Management Offices 18 Floor, The Curve Bury New Road Prestwich Manchester M25 3BL Tel: 0161 3581602 Our Ref:BH/kearsley19.05.16 434 Web: www.gmw.nhs.uk 19" May 2016 |W Ge www om. nhs Miss Kearsley igo Bn tute] Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Miss Kearsley Re: Regulation 28: Dennis Bennett (Deceased) | am responding to the Regulation 28 you issued to the Trust on 11" April 2016. Whilst Mr Bennett's death was expected on the ward and the concerns you raise are not related to his death, or his care, or treatment, you note that there is a concern that a lack of understanding and differing information about the Deprivation of Liberty (DoLs) process may and could impact on other patients. For ease | will answer each concern separately. You note that the Trust staff completed an application for an urgent DoLs at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act. The use of DoLs is rare within the Moorside Unit and Bollin/Greenway Ward. In order to ensure staff have a good understanding of the DoLs process and its relationship to the Mental Health Act senior clinical staff will be provided with further bespoke training about Dols which will incorporate the concerns you raise. A further concern was raised that there was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. In order to avoid any further miscommunications and because the use of DoLs on the Moorside Unit is rare the Mental Health Act Administrator has been asked to ensure a summary email is sent to the Council when taking advice. This will ensure any miscommunications are picked up by either party promptly and allow for the correct information to be communicated. Nationally it is reported that there are an increasing number of situations in which an application for standard and urgent authorisation for DoLs has been made by the Managing Authority but the Supervisory Body has not granted the standard authorisation by the time the urgent authorisation has expired. This situation is not provided for in the legislation or code of practice. Therefore, there is no straightforward legal solution to the problem. The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment. Greater Manchester West Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. Trangie of Core MEMEER © & Greater Manchester West NHS Mental Health NHS Foundation Trust Staff completing applications will be asked to consider the following if this situation arises again. Apply to extend the urgent authorisation. The Head of Operations will write to the Supervisory Body to ask them to set out their reasons for the delay and will also enter into discussion at a senior level to resolve the situation. As patients’ needs change frequently further consideration will be given to whether it is appropriate to use the Mental Health Act as the least restrictive option. Similarly, the patients care plan will be reviewed to establish if aspects of the care plan can be amended to make them less onerous and, therefore less likely to amount to a deprivation of liberty. The patient will be referred for an Independent Mental Capacity Advocate (IMCA) with the possibility of them engaging a solicitor to ensure that the patient's rights are safeguarded. You also note that the decision to apply for a DoLs was initially made at a time when the decision was for Mr Bennett to be moved to nursing home care. Indeed, the evidence provided by the family was that a DoLs application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DoLs are place specific. | can confirm that in order to ensure all staff have an increased knowledge about DoLs the staff group have been asked to complete a DoLs training package which includes this information. The completion of this training is mandatory and will be monitored by the ward manager. The additional bespoke training being delivered to senior clinicians will also include this information. If a DoLs is undertaken in the future, an explanatory leaflet will be given to the patient’s family to reaffirm any verbal explanations that have been given. It can often be a difficult time for families and carers and it is hoped that by giving supportive information it may help families better understand the reasons why a Dols is being applied for, the parameters of this as well as informing them of the patient’s rights. Finally, you note Mr Bennett was then on the end stage palliative care and entirely compliant with treatment, there was little consideration as to why a DoLs was applied for as opposed to treating the deceased in his best interests. The decision to place the patient on a DoLs rather than act in his best interests whilst initially appears incorrect, has been reviewed by the Trust Social Care lead and the Directorate Social Care Lead and is considered to be available to the clinicians providing care and treatment in this particular case. The Deprivation of Liberty safeguards provides a legal framework to deprive someone of their liberty whether they are making attempts to leave or not and does not have Capacity to make an informed decision (Mental Health Act 1983 Code of Practice 13.45). The Trust’s Clinical Improvement Lead Nurse for Dementia, Older People and Carers Services is currently undertaking a review of end of life care. She has been asked to build into the review consideration of the most appropriate legal framework to use. The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment, Greater Manchester West Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL. Tel: 0161 773 9121. oo Triangse of Care NEMBER && Greater Manchester West INHS| Mental Health NHS Foundation Trust | hope this response provides assurance to you and Mr Bennet’s family that GMW have taken the learning from the inquest very seriously and have put in place measures to ensure safe and effective services. Yours sincerely Bev Humphrey Chief Executive The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment. Greater Manchester West Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. oo Triangle ef Care NENEER &
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