Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0208, written 2 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2016 |
|---|---|
| Reference | 2016-0208 |
| Deceased | Jessica Birkhead |
| Coroner | John Tomalin |
| Coroner area | Exeter and Greater Devon |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Seaton & Colyton Medical Practice
148 Harepath Road
Seaton
Devon
EX12 2DU
2. Northern, Eastern and Western Devon Clinical Commissioning Group
Newcourt House
Old Rydon Lane
Exeter
EX2 7JU
CORONER
{ am John G. Tomalin, Deputy Coroner for the coroner area of Exeter and Greater
Devon.
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 31 July 2015 | commenced an investigation into the death of Jessica Mary
BIRKHEAD aged 30 years. The investigation concluded at the end of the Inquest on 20
May 2016.
The conclusion of the Inquest gave a Medical Cause of Death of:
‘ta, Acute Hepatic Necrosis (probably due to Paracetamol toxicity) and Pregabalin
overdose.”
The Narrative Conclusion was given stating:
“Jessica Mary BIRKHEAD died on 28 July 2015 from Acute Hepatic Necrosis (probably
due to Paracetamol toxicity) and Pregabalin overdose, a drug not prescribed for her, at a
time when her judgement was impaired as a result of her existing medical conditions”.
CIRCUMSTANCES OF THE DEATH
Mrs Birkhead was born with Down’s Syndrome (mosaic variety) and associate learning
difficulties. She also suffered from a depressive illness, with possible psychosomatic
symptoms secondary to psychosocial stressors.
On the 28th July 2015 Jessica’s husband called emergency services when he found his
wife unconscious. Jessica was taken to the Royal Devon & Exeter Hospital where she
died at 14.40 hours the same day. The pathologist concluded Jessica had ingested a
large quantity of Paracetamol but was uncertain as to whether this was potentially a
build-up of that drug over a prolonged period. She had also ingested a large number of
Pregabalin tablets, a drug not prescribed for her, but her mother-in-law who lived in the
same household.
GORONER’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. Although Jessica had been referred to a Consultant Psychiatrist in learning
disability, the other support services offered to Jessica were main stream adult
services, Jessica’s mother, a GP, is of the view that they were not equipped to
deal with someone of Jessica’s intellectual disabilities.
2. Perhaps Jessica’s case could be looked at to consider the appropriate pathway
for others in the future in a similar situation to Jessica to give appropriate
support and care at a level appropriate taking into account any learning
difficulties and associated medical problems.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and 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 28 July 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 sent a copy of my Report to the Chief Coroner and to the following Interested
Persons:
1. BE (:1.sanc of Deceased)
| 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.
Signed
John G, Tomalin
Hil Deputy Coroner
Dated this 2" day of June 2017
2 responses 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.
RECEIVED - 4 AUG 2016 INHS| HEALTHY PEOPLE Northern, Eastern and Western Devon Clinical Commissioning Group living healthy lives in-healthy: communities Private & Confidential NHS Northern, Eastern & Mr J Tomalin Western Devon Clinical Exeter and greater Devon Coroner’s Office Commissioning Group Room 226 The Annexe Devon County Hall County Hall Topsham Road Topsham Road Exeter Exeter EX2 4QD EX2 4QL Date: 27/07/2016 Dear Mr Tomalin Re: Jessica Mary BIRKHEAD Deceased DOB. 28/07/2015 Inquest held on 20 May 2016 at Devon County Hall, Topsham Road, Exeter Regulation 28 Report | am writing to you in response to your letter dated 02 June 2016 to NHS Northern, Eastern and Western Devon Clinical Commissioning Group (CCG). Please see below the CCG response to the matters of concern identified in the Regulation 28 report. In terms of context, the CCG’s approach to commissioning access to mainstream healthcare services for people with a learning disability is in accordance with national policy. People who have a learning disability should have access to the same specialisms as the general population, whilst recognising that reasonable adjustments may need to be made in services to enable this access. It is not practical or indeed clinically desirable to run a host of parallel health services for people who have a learning disability as they should always be able to access the expert input they need as patients, for example in primary care, physical acute medical and surgical services or mental health services. This in turn will enable people with learning disability to use evidence based services supplied by members of staff with the appropriate skills who are supervised and trained according to their specialist function. This is a widely supported position intrinsic in government policy and research such as;- . e Improvement, expansion and reform ensuring that ‘ail’ means ‘all’ DH 2002 ¢ Equal treatment closing the gap (DRC 2009) e Improving the Health and Wellbeing of People with Learning Disabilities: An Evidence-Based Commissioning Guide for Clinical Commissioning Groups (CCGs) ¢ Valuing People Now (DH 2001) e Valuing People Now (DH 2009) The CCG fully recognises that people in our community who have different needs may need different approaches to care and the duty under the Public Sector Equality duty (2011) for public sector organisations to ensure that services are reasonable adjusted. (1) Details of measures the CCG has implemented to assist people with learning disabilities to access appropriate main stream adult services and to support both the service user and the main stream adult services to ensure that appropriate care is provided The CCG has specifically commissioned services with Devon Partnership NHS Trust (DPT) to support the access of people who have a learning disability to mainstream services. In primary care there are approximately 20 nurses operating across Devon to ensure that individuals have good support in primary care services. This is a significantly higher level of service than other CCG’s. The Extended Service provision of Annual Health Checks in Primary Care for people with learning disabilities has been maintained. In addition work has taken place with the locality screening teams (Cervical cancer, Bowel Cancer, Abdominal Aortic Aneurysm, Breast cancer and Diabetic Retinopathy) and immunisation teams (influenza) to increase uptake of these services by people with learning disabilities. In secondary care there is an Acute Care Liaison nurse in all of the large general hospitals in Devon and additional liaison learning disability nurses offering support. The specification for this service is explicit stating it is there ‘to provide a link between social care/community learning disability teams/primary care and facilitate health promotion supporting people to access other health services i.e. chiropody, dentistry, mental health services district nurses etc.’ In addition the specification states that this service will “support good mental health outcomes and access to all universal mental health services” The intensive assessment and treatment team (IATT) in learning disabilities also offered support in this case and is there to support direct input to the person if they are experiencing behavioural problems. The current service specification states that ‘...therefore a key function of the team is to enable advice and support to those agencies to make sure those reasonable adjustments happen in those other services. ...’ and ‘ATT is not a crisis intervention service’. Mental health, physical or social care crisis should be dealt with through the normal services. However IATT staff will support and advise those services offering guidance where appropriate.” Mental health services such as the Depression and Anxiety Service (DAS) are able to identify vulnerability and make reasonable adjustments where required to enable people with learning disabilities to access services. From the root-cause analysis report completed by DPT it is noted that regular conversations had taken place between mental health services and learning disability services. Services appeared responsive and caring with a wide range of input in place. (2) Details of further measures the CCG plans to take in the future to assist those with learning difficulties to access appropriate main stream adult services or to support both the service user and main stream adult services to ensure that appropriate care is provided. The “Green Light” audit tool (NDTi, 2013) has previously been deployed to review and benchmark inpatient services response to people who have mental health needs and also a learning disability and/or autism. The CCG clinical and quality leads will assess with the leads of relevant provider organisations whether this tool could appropriately be applied to other community services to provide a review of access of mental health services to individuals and to identify what further reasonable adjustments are needed in services to enable service improvement. Assessment and agreement as to how this tool can be appropriately deployed will be completed in 2016/17 in order to inform any quality improvement initiatives to be undertaken in 2017/18. | trust that this response addresses the matters that you have raised in your report, however should you have any further questions please do not hesitate to contact me. Yours sincerely Managing Director, Joint Commissioning Northern, Eastern and Western Devon Clinical Commissioning Group " htto-/www.ndti.org.uk/uploads/files/Green Light Toolkit 22 Nov_2013 final.pdf
The Seaton & Colyton Medical Practice
148 Harepath Road
Seaton
Devon EX12 2DU
Tel: 01297 20877
Fax: 01297 23031
Mr John G Tomalin
HM Deputy Coroner
Exeter and Greater Devon Coroners’s Office
Room 226 Devon County Hall
Topsham Road
Exeter
Devon EX2 4QD
20 July 2016
Dear Mr Tomalin
Re: Mrs Jessica —_ BIRKHEAD (D.0.B. 07.06.1985) deceased 28 July 2015
{ am writing in response to your letter addressed tof dated 02 June 2016. | wrote to
you on 08 June 2016 and | note your letter dated 07 July 2016 in which you state that you are
happy for my response to the Regulation 28 Report made into the death of Jessica Birkhead,
which | have prepared on behalf of 7 who has retired, and the current partners at the
Practice. .
| take note of the contents of the Regulation 28 Report and in particular your concerns as stated
in note five of the report.
Jessica first moved into the East Devon area in August 2006 when she was registered at the
Honiton Surgery. At the time she had moved from a specialist unit in Minehead to live in a
specialist care home in Honiton. She had a case manager and care worker. In addition, she
was referred to a clinical psychologist who worked with her over the following year. She saw her
GP regularly and following completion of the work with the clinical psychologist was referred to
the East Devon Learning Disability Team in November 2007. She continued to have regular
health checks with her GP while she lived in supported accommodation.
In December 2012 she was registered at the Devon Square Surgery in Newton Abbott. She was
_ teferred to a consultant psychiatrist in March 2013 by her GP.
She then moved to Colyford to live with her husband, baby and mother-in-law. At this time she
registered with the Seaton & Colyton Medical Practice. She was reviewed by
Consultant Psychiatrist with the Learning Disability Partnership on-05 April 2013 who set out a
clear plan for her care. Thi shared with her social worker and clinical psychologist. She
was reviewed again by ee July 2013. Following this she had a further clinical
psychology assessment between June and September 2013. She was reviewed again by
Consultant Psychiatrist with the Learning Disability Partnership, in October 2013 with
the plan to keep her under regular review. There followed further assessments in March 2014
and June 20174.
-2-
20 July 2016
Re: Mrs Jessica Mary BIRKHEAD (0.0.8. 07.06.1985) deceased 28 July 2015
NHS No. 474 405 1022 .
Subsequent to this [Een HE suggested that Jessica might be referred for cognitive
behavioural therapy and referred her to the Depression and Anxiety Service. She was reviewed
again by | October 2014. She continued to have regular contact with her GP and had
a full learning disability health assessment in November 2014 coordinated by inal worker.
She also had further appointments with the Depression and Anxiety Service. saw her
again on 18 March 2015 when she was accompanied by her occupational therapist from the
Community Learning Disability Team. She remained under the care of the Learning Disability
Team and consultant psychiatrist. She also remained under the care of the Depression and
Anxiety Service having been rereferred to them in April 2015.
Jessica sadly died on 28 July 2015 having taken an overdose. There is no reference in her
primary care records that she expressed to her GP any thoughts of deliberate self-harm. | take
note with regards to the “Matters of Concern” raised under Regulation 28. However, it is my
opinion that Jessica was under the care of a consultant psychiatrist specialising in learning
disabilities, the Devon Learning Disability Team and also the Depression and Anxiety Service,
as had previously been arranged by two consultant psychiatrists. It is not, therefore, my view
that the support services were not equipped to deal with someone of Jessica’s intellectual
disabilities.
The Seaton & Colyton Medical Practice held an informal Significant Event Audit Meeting
. following Jessica's death, following which fe provided a report to the Coroner as
requested. Following receipt of the Record of Inquest and taking particular regard to the
Regulation 28: Report to Prevent Future Deaths, the practice will hold a formal Significant Event
Audit Meeting in which we will discuss Jessica’s case and consider appropriate pathways for
others in the future in a similar situation to Jessica to take into account any learning difficulties
and associated medical problems.
| trust that this reply is satisfactory and we will forward the results of our Significant Event Audit
when it has taken place.
Yours sincerely
RECEIVED 2 2 JUL 2016
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