Adele Blakeman

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

Chief Executive ;

South West London and St George’s Mental Health Trust,
Springfield Hospital,

61 Glenburnie Road,

London.

SW17 7DJ

Chair, NHS Care Commissioning Group
73 Upper Richmond Road

London

SW15 2SR

CORONER

1am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London

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.

INVESTIGATION and INQUEST

On 8" November 2016, and 25" November 2016, I heard the inquest touching
the death of Jaroslaw Rogala (otherwise known as Jarek).

Medical Cause of Death

1 (a) Hanging

How, when and where and in what circumstances the deceased came by her
death: :

Jarek was dependent on alcohol. When intoxicated he suffered with suicidal
ideation. On 3/9/2016 he was found hanging in his bedroom deceased. There
were no suspicious circumstances. He was heavily intoxicated at the time of his
death. : :

Conclusion as to the death

He took his own life whilst intoxicated with alcohol

CIRCUMSTANCES OF THE DEATH

In the days leading up to his death he had attended St.George’s Hospital on the 30" and
31 August consecutively with suicidal ideation in association with social stress and.
alcoho! misuse. On each occasion he was seen by Liaison Psychiatry and discharged to
GP follow up. Admission had been requested but he was told that there was nowhere
that he could be admitted to. He was not sectionable under the Mental Health Act. In
evidence the court heard that there is no facility to admit patients in whom the primary
diagnosis is dependence on drugs or alcohol under the psychiatric services in such
circumstances. Further admission under the medical teams for detoxification requires a
medical indication. As such there is no ability to admit such a patient into a “safe” space
when in crisis for care and supervision. Essentially patients with dependence are thus
discriminated against by psychiatric services, with addiction being regarded as a
personal choice on the part of the patient rather than being treated as an illness.

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. —
That those patients with addiction are risk of suicide as there are no in-patient facilities

to admit them for care and supervision when in crisis in circumstances as described in
this case.

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. |,
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 :

| 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.

44™ December 2016

Dr Fiona J Wilcox

HM Senior Coroner

Inner West London
Westminster Coroner’s Court
65, Horseferry Road

London

SW1P 2ED

GREATER MANCHESTER

Chief Constable

Ms Joanne Kearsley
Area Coroner
The Coroners Court, 1 Mount Tabor

Stockport
SK1 3AG 23” June 2016

Dear Ms Kearsley
Re: Adele Bernadette Blakemen (deceased)

Thank you for your report sent by letter dated 15" April in respect of Adele Bernadette
Blakeman deceased pursuant to Regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013 and paragraph 7, Schedule 5 of the Coroner’s and Justice Act 2009.

| reply to your concern as follows;

Extract from Regulation 28, report point 1. The GMP computer system hinders
officers and does not afford them easy access to important information within the
timescales they have available to them, in order for them to adequately assess a
situation. Concerns around the efficiency of GMP’s antiquated computer system
have been raised now on a number of occassions and have featured in several

inquests.

GMP is investing significantly in the replacement of technology through the IS
Transformation Programme to replace existing separate command and control, custody,
intelligence, work allocation, and property systems with one user experience and a more
intelligence information management process that enables partner agency information
sharing (iOPS). The programme will also improve integration of components outside of these
core systems, replace ageing data warehouse capabilities and moving to a data centre
managed externally by a reliable supplier. Also as part of this programme of work, mobile
technology is being distributed to operational staff which is already demonstrating through a
pilot site a significant forwards steps in information access, input, and decision-making. This
mobile technology will enable frontline officers responding to calls to have direct access to
GMP IT systems and the important information they contain.

Given the complexity of this change programme, GMP is undertaking a comprehensive
procurement, design and testing process before implementation which is currently scheduled

for late 2017.

Extract from Regulation 28, report point 2. There is a failure to record pertinent
information about an individual on the intelligence section of an individual nominal
profile. There were 5 PPI logs available to officers, no crucial pertinent information
from these logs had been placed in her intelligence section, officers would have had
to access each of these logs individually and read through the entire entries to elicit
any inforamtion which may have been relevant. For example the fact that 4 of them
involved this individual attending at railway stations or level crossings with a view to
attempting to commit suicide. There was also on one mention of involving BTP
should there concerns about this individual, this partnership working was lost in the
midst of one PPI log.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Cont.d pg 2 ........

In respect of PPI logs, it is the responsibility of the officer submitting the PPI to submit any
relevant intelligence from within the report.

By the end of August all supervisors from within the Public Protection Investigation Units and
who are responsible for the finalisation of any vulnerable adult PPIs will be reminded that on
finalisation they must quality assure the PPI along with ensuring that intelligence is submitted
were appropriate. This will also give them the opportunity to review any warnings, in the
case of Adele both a suicidal and self harm warning would have signposted the user to the
fact that within that record there is information pertaining to the reason for the warning.

GMP do still receive information from British Transport Police. They come in two formats,
one of which is managed through the Force Intelligence Bureau and the other via Divisions.
From here on in the FIB will ensure that a record of the existence of both is inputted onto the
nominal action board along with any trigger plans. is taking this forward
and will fook at ways to improve any information sharing agreement.

Extract from Requlation 28, report point 3. There was a failure to esculate this call as

per the escalation procedure to a divisional Inspector for a review.

It is accepted that this case was not escalated to a divisiona! inspector as it should have
been.

In March 2016 Chief Inspector 05718 IEEE from the Operational Communications
Branch (OCB) revised the FWIN Escalation Policy the revised version is currently at the end

of the consultation phase.

The new FWIN Escalation Policy sets out a process for both OCB staff and divisional
supervisors to make informed decisions about the escalation of incidents using the National
Decision Model (NDM). In principle, it aims to ensure resources are deployed to deal with
any incident in a timely manner based purely upon threat, risk and harm, and not based upon
the existing time based escalation points as per the existing policy document.

It is anticipated that the new policy will be in place by August 2016.
Extract from Regulation 28, report point 4. There is a lack of understanding of the

role of the IMU in missing person enquiries.

In January 2014, appreciating the threat, risk and_harm that is constantly being managed
within the OCB Chief Superintendant 15066 IE implemented a Risk Support
Team (RST).

The RST is an interim measure to support the overall function of the OCB in managing
threat, harm and risk alongside the wider organisational learning that has been identified
from Regulation 28 notices, IPCC recommendations and critical incidents.

The role of the RST is to support command and control by identifying risk and vulnerability to
victims, offenders and police officers as well as other members of the public. The RST
conduct background intelligence checks that are far more detailed and complex than those
carried out by divisional radio operators using some systems that only the RST have access
to. This is predominantly done by trawling the iS queues, scrutinising all incidents regardless
of grade and summary heading.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Cont.d pg 3 ....

The RST also deal with:

FWINS that have been switched, where a radio operator feels there is a requirement
for enhanced checks, where there is already a greater concern of risk.

Incidents that require time consuming telephone enquiries

Liaison with partners, especially when checks reveal that they are the most suitable
agency to deal.

Assisting with critical incidents and some high risk MFH enquiries.

Protracted enquiries to try and locate a victim when we have not managed to
establish contact.

Searching FWINs closed on G16 (vulnerability) and update the KH details with
pertinent information.

Merger of duplicate OPUS records

Staffing on the RST consists of one supervisor and 5 teams of 2 staff, all of whom foliow the
command and control shift pattern, covering from 0700 to 0200/0360.

In light of this regulation 28, the role of the Information Management Unit has been
highlighted throughtout the OCB via inclusion on Divisional Orders on 27th May 2016. This
highlights their role in the triage of MFH incidents amongst their other duties.

Aditionally in May 2016, Professional Standards Branch chaired a organisational learning
meeting with OCB, Public Protection Division and the Force Missing From Home Manager. It
is proposed that we will be able to report back to the Coroners in July 2016 in terms of the
wider work being completed around vulnerability, including the lessons learnt from this case.

Yours sincerely

Sh

<5

lan Hopkins
Chief Constable

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

South West London and St George's NHS

Mental Health NHS Trust

17
59) 0% “ -
Chief Executive’s Office

Building 15 Top Floor
Springfield University Hospital
61 Glenburnie Road

London SW17 7DJ

PA: T.020 3513 6385

Web: www.swistg-tr.nhs.uk

10 February 2017

Dr Fiona J Wilcox

HM Senior Coroner
Westminster Coroner’s Court
65 Horseferry Road

London :

SW1P 2ED

Dear Dr Wilcox
Regulation 28: Report to Prevent Further Deaths

| am writing to you following. receipt of the Regulation 28: Report to Prevent Future Deaths
dated 15 December 2016 regarding the sad death of Mr Jaroslaw Rogala (known at Jarek) as
a result of hanging. Your report indicates that Mr Rogala was heavily intoxicated at the time of
his death and was dependent on alcohol. You have requested South West London and St
Georges Mental Health NHS Trust (Trust) to respond to whether those patients with addiction
are at risk of suicide, as there are no in-patient facilities to admit them for care and supervision
when in crisis in the circumstances as described in this case.

In order to thoroughly examine all of the concerns a meeting was convened_on 20" Januar

2017 by memset Director for Wandsworth within the “—
Head of Mental Hea ommissioning, Wandsworth Clinical Commissioning Group (CCG) il
HE Consultant Psychiatrist, Merton Drug and Alcohol Action Team, and separate
input was provided | Consultant Psychiatrist, Psychiatric Liaison Service
at St George’s Hospital. The meeting reviewed the details of the case and whether there were

missed opportunities, as well as the possibility of gaps in the current framework of services
that may have prevented Mr Rogala’s death.

We established that Mr Rogala experienced suicidal thoughts and minor self-harm when
intoxicated on alcohol, although on both of the occasions he was seen by psychiatric liaison
services at St George’s Hospital these experiences had resolved and he denied any suicidal
intentions when interviewed. During both of the assessments he was found to have capacity
to make decisions about his treatment, and the offer of referral to community alcohol services
was made, which he made a capacitous decision to decline. Furthermore we can find no
record of Mr Rogala requesting admission to hospital although we can see that his partner was
very supportive and concerned about his well-being.

Chief Executive, David Bradley Chairman, Peter Molyneux

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Compassionate Consistent

me South West London and St George's INH!

Mental Health NHS Trust

The possibility of a-gap in service provision has been considered in the event of the
circumstances of the case being different, for example: if Mr Rogala had been assessed as
suicidal in the context of alcohol dependence and to be requesting admission to hospital. If
this had been the case, psychiatric liaison services would have explored a range of options
with the aim of the risk of him acting on his thoughts being alleviated. This may have led to a
referral to the home treatment service which is able to provide intensive support for people
who are suicidal, regardless of the presence of alcohol or any other form of addiction. The
outcome of the assessment by the home treatment service would also influence whether
admission into inpatient care was appropriate or not, again this is an option regardless of the
presence of alcohol or any other form of addiction, and would be focused on the risks of Mr
Rogala acting on his suicidal thoughts.

In fact, with the support of our Commissioners, local services for patients in mental health
crisis have improved since the time of Mr Rogala’s contact with our services, and this may
provide you with further reassurance. Since November 2016, clinicians working in the Trust’s
Emergency and Urgent Mental Health Services (including Liaison Psychiatry and Home
Treatment teams) have been able to offer higher risk consenting patients the option of transfer
to the Lotus Psychiatric Decision Unit (PDU). The Lotus suite enables patients to be
supported and monitored for up to 48 hours in a dedicated safe space at Springfield University
Hospital and permits an extended assessment to be undertaken. The outcome of this could
indicate a formal admission to an acute psychiatric ward, or some other form of support.
Again, the presence of suicidal ideation is the focus of the care plan, and the existence of an
addiction, is not an exclusionary factor. You may also wish to know the Trust is due to open
two ‘crisis cafes’ in April 2017 located in Wandsworth and Merton boroughs that will provide
open access spaces on high street locations for people in mental health distress.

From our consideration of the case and the criteria of existing services we therefore do not
believe that patients with an addiction are discriminated against when a co-existing mental
health crisis, such as suicidal ideation, is identified. Where significant risk is indicated, the use
of the Mental Health Act may also be considered to ensure a patient is conveyed to a place of
safety for ongoing assessment even when they are not agreeable. However, the use of the
Mental Health Act was not an option in the case of Mr Rogala as his risk was not determined to
be high at the time of assessment; he had a primary dependence on alcohol which is an
exclusion under the Mental Health Act; and he had capacity to make decisions himself.

We have also considered whether there is a possibility that local services are in some way. out
of step with services in other parts of the country. In this case the psychiatric liaison nurse
offered to refer Mr Rogala to community alcohol services that serve the area (Merton) in which
he resided. If Mr Rogala had wished for the referral to be made, an appointment to attend
Merton Drug and Alcohol Action Team would have been forthcoming, and this would have led
to a personalised offer of support, depending on the outcome of the initial assessment. For
some patients this can also lead to exploring the benefits of a planned admission to a
dedicated inpatient detoxification unit. As you are aware, Mr Rogala had been through two
previous alcoho! detoxifications in 2016. The existence of a crisis inpatient facility for patients
with alcohol dependence has been highlighted in the Regulation 28 Report although there is
little indication that Mr Rogala was at immediate risk when assessed, or that he wished to
access such a service. Should such needs have been identified in Mr Rogala, the nature of
any risks would have indicated referral to mental health services as highlighted above, which
may have ultimately led to admission to an inpatient facility as a protective measure.

Chief Executive, David Bradley ; Chairman, Peter Molyneux

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South West London and St George's [AY/

Mental Health NHS Trust

Our deepest sympathies are extended to the family and friends of Mr Rogala. The conclusion
that we have reached indicates there is no current gap in services that would have prevented
him accessing a safe place, and the criteria for accessing crisis support from mental health
services do not discriminate against those patients who are in crisis-due to the presence of an
addiction, other than the statutory exclusions written into the.-Mental Health Act. In discussion
with CCG commissioners who are the responsible body for commissioning a full range of
services, including mental health and substance misuse services, the Trust also believes the
framework of services within Wandsworth and Merton to be in line with arrangements in other
parts of London, and consistent with the overall national picture.

Yours sincerely

David Bradley SS

Chief Executive Officer

Chief Executive, David Bradley Chairman, Peter Molyneux

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=} Compassionate