Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0400, written 8 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Dec 2016 |
|---|---|
| Reference | 2016-0400 |
| Deceased | Sandra Brotherton |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Care 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: Pennine Care NHS Foundation Trust CORONER Tam Joanne Kearsley Acting Senior 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 30th November 2016 I concluded the Inquest into the death of Sandra Brotherton date of birth 10.07.1954 who died on the 31.12.14 at her home address in Bredbury Stockport. The cause of death was 1a) Multiple Stab Wounds I recorded that the deceased died on the 31% December 2014 at her home address. She was killed by an individual who had a dual diagnosis of paranoid schizophrenia and Aspergers. For several days the deceased had been in hospital and the individual who had no insight into his illness at been at the home address alone. It is probable that he had not been eating, sleeping or taking his medication during this period of time and had experienced a breakthrough in his symptoms. When the deceased arrived home he was exhibiting agitated and disturbed behaviour and killed the deceased a few hours after she arrived home. Conclusion — Unlawful Killing CIRCUMSTANCES OF THE DEATH The Inquest into the death of Sandra Brotherton was resumed following a criminal trial in which the offender, had been sentenced to a hospital order. There were matters of concern raised surrounding his involvement with Mental Health Services. had a dual diagnosis of Paranoid Schizophrenia and Aspergers Syndrome. He had been sectioned many years ago for a short period of time but had subsequently been cared for at the home address by Sandra Brotherton who was predominantly his sole carer. prompting to do many daily tasks including washing, dressing, eating and taking his medication. HE was described by several witnesses as someone who had residual symptoms of his psychosis and lacked understanding and insight into his condition. He never accepted that he was unwell Sandra was the focus of | | aggressive behaviours and we heard evidence of the arguments which might occur between them and o name calling of over many years when he called her such things as “witch and satan”. Sandra as the main carer and indeed main person in life who bore the brunt of his behaviour and verbal aggression. Package of Care in place for ll The Court heard howl was under the care of mental health services. He was treated with medication which was reviewed and until 2014 he was under the care of the Community Mental Health Team, EIT. This was then transferred to Recovery and Intervention Team (RIT). Under both services had a care co-ordinator. Indeed the difference on a practical level for was the change in his worker. In addition had a Personal Assistant which was paid for through the Direct payments scheme of the local authority who had been in place since 2006. Contingency Plans Given that Sandra was effectively the sole carer fo questions were asked at the Inquest as to a contingency plan in place should Sandra not be in a position to care for J At times the evidence on this was interlinked with the plan for respite care but overall the contingency plans for were simply having provided contact details for the Access and Crisis teams and the Home Treatment team and believing that family were close and on hand to provide support. Information Provided to PA and interaction with Mental Health Services i confirmed it was not until afteiME death that he was aware of d iagnosis of Schizophrenia. His understanding was that Mental health services were involved because off diagnosis of autism. was clear that he received his instructions from Sandra. He had very little contact with care co-ordinator although there were occasions when he would see her. It was clear from the evidence that Mh was included in the care plan for but as he stated in his evidence, “ he would not know if he was.” The mental health team were not aware when a. would be on leave — HE the RIT Team confirmed that she would have expected that the RIT team were aware of when the PA was on leave and would have expected increased visits by the care co-ordinator during this time also accepted she could have increased her visits had she known the PA would be away. No August 2014 and Incident on the 18"' September The Court heard evidence of involvement with and Sandra throughout the August and September of 2014. In August 2014 had received a call indicating was unwell and she carried out an urgent home visit. She indicated that she could see he was unwell, he was agitated, she stated though that he was not delusional. At this stage she advised howl was on leave and she spoke to another Dr who agreed to increase JJ) Olanzapine medication. The Court also heard that during this time she tried to get an urgent appointment with a Consultant Psychiatrist but this was not possible. A month later the Court then heard evidence about the incident which occurred on the 18" September. Sandra told her daughter that lM had lashed out and hit her in the face. There was also some evidence she also told her husband who was abroad but may not have told him the full details. We know that she told her sister that IMB had hit her, saying that HE had tripped and had not meant to do it, she was convinced it was a one off. Also told her sister | who felt that IMM had crossed a line and urged Sandra to seek help. In addition she did tell EE that III had lashed out at her but when asked, she said that she had reported it to MM care team. Sandra did telephone Mental health services on the 18" September — at no stage in any of the conversations did she say that Il had assaulted her. We know that she did ring saying that he needed to be re-housed immediately. in her evidence described “trying to make sense of the reasons Sandra wanted Hiilout of the property” and recalled her being “vague”. She recalled “it was almost as if Sandra just wanted him out of the house not that she felt at risk”. Sandra was asked about risk and told ) who documented the same that she did not feel at risk. December 2014 Sandra was unwell over the Xmas period and had attended hospital on the 22- 23™ December. She then reattended and was admitted on the 28" December. At no stage were Mental Health services aware of her admission. When she returned home on the 31* December 2014 she was killed a short time later. CORONER'S CONCERNS The concerns noted by the Court during the course of the Inquest are as follows: 1) Knowing that Sandra was in effect a sole carer there should have been a clearly discussed contingency plan fo in the event that there was an emergency and Sandra was not able to provide care. Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person, where there is no suggestion of a lack of capacity, this should be recorded. It was concerning that the Care Co-Ordinator who visited [A in August 2014 was not able to obtain an urgent appointment with a Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with a dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence as to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of an assault but suggestive of a potential issue involving a Mental Health service user and it is for this reason that I do find that there should have been an attempt to see or speak to to see how he was, after there had been a suggestion that he needed to leave his him immediately 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 report, namely by 2™! February 2017 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. COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family and legal representatives of the family of Sandra Brotherton. I 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. 08.12.2016 Joanne Kearsley Acting Senior Coroner
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.
Pennine Care INHS NHS Foundation Trust | Corporate Govern ace Trust Headquarters 225 Old Street Ashton-Under-Lyne rd Lancashire 23" February 2017 | OL6 rer | PRIVATE & CONFIDENTIAL Ms J Kearsley Acting Senior Coroner Our Ref: KB/ELD Manchester South Coroner’s Court Department: Trust Headquarters 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Kearsley, Re: Sandra Brotherton (Deceased) Thank you for your Regulation 28 report dated the 13° December 2016, and for bringing to my attention the concerns you had after hearing all the evidence. Your concerns relevant to Pennine Care have been reviewed, and the Trust's response is outlined below. | | | Concern 1: . “Knowing that SB was in effect a sole carer there should have been a clearly discussed contingency plan for DB in the event that there was an emergency and SB was not able to provide care.” Response: The Trust records audit has been reviewed and amended. This has gone live within services from week commencing 30.01.17. Question 26 of the audit asks if there are detailed actions to take to manage/mitigate risk (e.g. triggers/crisis and risk management plans). Question 26 also asks if a crisis management / contingency / prevention plan is in place. Care Coordinators within Stockport Community Services have been reminded that it is their responsibility to develop contingency plans in collaboration with the identified carer in the event of any emergency situation where they are unable to provide care, such as the care being admitted to hospital. Care Coordinators will ensure this is clearly documented in the service user's care plan. To share the learning highlighted in your concern a 7 minute briefing has been developed regarding contingency plans in the absence of the main carer and this has been shared with all community based mental health teams in the Trust. The briefing recommends that where a servicejuser’s care in' the community is reliant on the support of a carer, a contingency plan ‘should be agreed and documented in the care plan for when the main carer is not able to provide care. Community Team Managers have delivered the briefing to teams, to reflect on the findings and recommendations in the briefing, to discuss the retain for individual practitioners practice and for the service or team. Hi gt have been asked to outline the steps they will take to improve practice in line with the recommendation. Recommendation. To be discussed at the Tier 4 (Trust-Wide Strategic Group, which oversees Community Mental Health Services) meeting to discuss adding guidance as an addendum to current operational policy for each community based team. Concern 2: . “Where a Personal Assistant is integral to the Mental Health Service care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person, where there is no suggestion of a lack of capacity, this should be recorded.” Response: Penhine Care NHS Foundation Trust Care/Programme Approach Policy was updated in November 2016 to provide guidance on assessment and CPA care planning to clarify responsibilities and requirements where there are carers funded by direct payments. The Trust records audit has been reviewed and amended and question 30 of the audit asks if there is evidence carers/others know who to contact in a crisis, if there is evidence of communication to other agencies involved in the care of the service user, and that other agencies involved in the service user’s care have received a copy of the plan. This has gone live within services from week commencing 30.01.17. Care Coordinators within Stockport Community Services have been reminded that in line with the CPA policy, version 12, where a Personal Assistant is in place with individual service users, the Care Coordinator will assess the need to share information with the PA based on risk. This must form part of the wellbeing care plan. To share the learning highlighted in this regulation a 7 minute briefing regarding the involvement of a PA in care planning processes has been developed and has been shared with all community based mental health teams in the Trust. The briefing recommends that where a Personal Assistant is integral to the Mental Health Service care plan there should be a clear and documented record that the care plan should be provided to them and that if there is an objection to confidential medical information being shared by the relevant person, where there is no suggestion of a jack of capacity, this should be recorded. Teams haye also been advised to review he updated CPA policy, which includes guidance where carers are funded by direct payments. Community Team Managers have delivered the briefing to teams, to reflect on the findings and recommendations in the briefing, to discuss the implications fdr individual practitioners practice and for the service pr team. They are fsa to outline the steps they will take to improve practice in line with ‘ecommendations. Recommendation: To be discussed at the Tier 4 meeting to discuss adding guidance as an addendum to current operational policy for each community based team. Concern 3: " “It was concerning that the Care Coordinator who visited DB in August 2014 was not able to obtain an urgent appointment with a Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with a dual diagnosis was required. Whilst his medication was increased at this stage he was not seen by a Consultant until October 2014.” Response: Pennine Care NHS Foundation Trust Care Programme Approach Policy has been ypdated in November 2016 to describe the role of he Consultant Psychiatrist with regard to the CPA policy and care policy. This will be discussed at the Tier 4 meeting where confirmation will be sought that community teams have a process for responding to crisis calls. Work around responding to crisis calls completed by Stockport Community Services will feed into the Tier 4 meeting for other boroughs to develop similar guidance locally. Confirmation will be sought that community teams in other boroughs have a process for responding to crisis calls. To share the learning highlighted in this regulation a 7 minute briefing regarding response to crisis calls has been developed regarding crisis calls and has been shared with all community based mental health teams in the Trust. The briefing recommends that community teams need to have triggers for responding to crisis calls and an escalation process in place. Community Team Managers have delivered the briefing to teams, to reflect on the findings and recommendations in the briefing, to discuss the implications for individual practitioners practice and for the service or team. They have been asked to outline the steps they will take to improve practice in line with the recommendation. Recommendation: To be discussed at the tier 4 meeting to discuss adding guidance a an addndum to current operational policy for each community based team. In order to provide you with further assurance that the Trust has reviewed all the concerns | attach a copy of the action plan that was produced in relation to ispues relevant to this lie case. | hope this response assures you that the Trust takes seriously any concerns that you raised. Yours sincerely, Michael McCourt Chief Executive
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