Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0392, written 2 Nov 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 Nov 2016 |
|---|---|
| Reference | 2016-0392 |
| Deceased | Michaela Thompson |
| Coroner | David Hinchliff |
| Coroner area | West Yorkshire (East) |
| Category | Suicide (from 2015) |
| Organisation named | Leeds and York Partnership 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS “| THIS REPORT IS BEING SENT TO: 1. HE vecical Director and Dr Sara Munro, Chief Executive of the Leeds and York Partnership NHS Foundation Trust 1 | CORONER | am David Hinchliff, Senior Coroner, for the Eastern Coroner Area of West Yorkshire. 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. 3 | INVESTIGATION and INQUEST On 2™ December 2015 | commenced an investigation into the death of Michaela Louise Thompson, age 36. The investigation concluded at the end of the Inquest on 19) October 2016. The conclusion of the Inquest was a Narrative, a copy of which | attach. The medical cause of death was:- 1(a) Hanging 4 | CIRCUMSTANCES OF THE DEATH The deceased was separated from her husband and lived with her two children aged 5 and 10, and had a medical history of suffering with depression. Mrs Thompson believed that she was suffering with a borderline personality disorder and/or bipolar disorder. These conditions had not been formally diagnosed. Miss Thompson had a long association with mental health services and was fully compliant with all treatment options. She had not been seen by a psychiatrist nor had any mental health assessment. She had regular suicidal thought culminating in her taking her own life by an act of self-suspension at her home address, her death being confirmed there at 1724 hours on 1* December 2015. _ 5 | 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) Michaela was the subject of two multi-disciplinary team meetings which were inadequately documented in the case notes. It should be clearly documented as to who was present and participating in such meetings. The identification of those involved should be clearly recorded, as should the outcome of and decisions made at such meetings. (2) On the morning that Michaela Thompson died, she had telephoned Aire Court in the _| presence of a friend who noticed that she became anxious and upset during that brief call. There was no record kept as to the nature of the call or any information or advice given, nor was the fact of the call immediately communicated to the Community Mental Health Nurse involved. Calls to the Service should therefore be recorded, to ensure that details of the nature of the call; its urgency; and the action taken by a named individual or individuals can be clearly ascertained. 6 | 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. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28" December 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Messrs Slater and Gordon Solicitors (representing the family), Messrs DAC Beachcroft LLP (representing L Foundation Trust) and Messrs Capsticks Solicitors LL! | 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. § | 2™ November 2016 Signed By wang _ 7p.
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.
Leeds and York Partnership NHS Foundation Trust Mr David Hinchliff S\CE \UC Consultant Psychiatrist Senior Coroner 2esx\5\ \ arte ca Ne ma Stree le Sco \WR - We © Leeds LS9 7BE Wakefield UL pray Sarr Tel: 0113 85 56713 WF1 3BS Fax: 0113 85 56736 Ref: GEVHB 29" November 2016 0 8 DEC 2015 RE: Inquest touching the death of Michaela Louise Thompson Dear Mr Hinchliff The letter and your regulation 28 requirements (attached)were forwarded to me for consideration. EES has now left his post and we have an interim medical director). | am aware of Miss Thompson's care and sad death therefore fully accept your requirement that there should be clear documentation as to who is present at multi-disciplinary team meetings along with clear documentation of any outcomes and decisions made. It is therefore something which we will of course put in place. | can also fully understand the rationale behind the second requirement as it was reported that Miss Thompson was distressed and anxious at the time of the phone call to Aire Court. It is clearly upsetting to the family who are unable to determine what was discussed in the phone call and who had that discussion with Miss Thompson. | have discussed this with the clinical team involved and they similarly feel that recording phone calls would be helpful for the future given their experience in this case. There are however some practical difficulties in that there are multiple phone lines coming into each team and these are used for a variety of reasons, sometimes by service users but also by other professionals and outside agencies. The practicalities of recording all of these calls could therefore be difficult. However, as agreed by the team, | do think the facility to record calls coming into clinical services is important and | agree with what | presume to be the rationale behind this requirement. | wonder though, given the likely practical challenges, whether it would be useful to discuss this a little further so that | am clear about you intend to be achieved by this so that we are able to do something that is both practically feasible and also meets both your requirements and those for people who use our services in the future. «proving he, . 4 A teaching organisation providing mental ime alth, IMproving live® health and learning disability services Leeds and York Partnership NHS Foundation Trust | would therefore ask if we could arrange a relatively brief meeting to discuss this so that we can implement it, in a way that addresses the concerns that you have identified? Yours sincerely CONSULTANT PSYCHIATRIST / CLINICAL DIRECTOR, LEEDS CARE GROUP jmproving health . 5 A teaching organisation providing mental : IMproving live? health and learning disability services
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