Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0057, written 16 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Feb 2017 |
|---|---|
| Reference | 2017-0057 |
| Deceased | Thomas Green |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| Category | Community health care and emergency services related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| 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 Churchgate Surgery Tameside oa Glossop CCG CORONER I am 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 29" November 2016 I concluded the Inquest into the death of Thomas Josef Green date of birth 15 November 1994 who died on the 10" June 2016 at his home address in Denton, Tameside Manchester. I recorded that the deceased had a complex background. He had been assaulted in 2011 and also involved in a road traffic collision. These together with other life events weil felt to have led to a diagnosis of post traumatic stress Hisorder. The medical cause of death was confirmed as 1a) Asphyxiation secondary to hanging Conclusion — Deceased had taken his own life CIRCUMSTANCES OF THE DEATH The Inquest into the death of Thomas Green had heard evidence that in August 2011 at the age of 16 he was assaulted. Following this he had difficulties leaving the house and became more isolated. On the first occasion he ventured out he was involved in a road traffic collision whereby as a pedestrian he was hit by a motor vehicle which didn’t stop, sustaining injuries to his head and legs. The Court heard that following this the deceaseds behaviour and personality totally changed. He was a virtual recluse, over time he became violent towards family members, he became paranoid and had mood swings. In September 2014 he was referred to the Early Intervention Team as he had expressed both suicidal and homicidal thoughts. Throughout October 2014 his violent behaviour escalated towards family members and on the 13" November 2014 he was sectioned under Section 2 Mental Health Act. He remained an inpatient under the care of MMMM from the 13.11.14 until the 5.12.14. During his admission he was diagnosed with Post traumatic Stress Disorder. Despite his inpatient Talus he was referred by ii on the 20" Novembet 2014 to General Adult Psychiatry due to his “mixed personality disorder with paranoid and antisocial traits.” It was unclear what happened with this referral but it was noted, as stated that this referral was made whilst Mr Green was an inpatient. | | Whilst an inpatient Mr Green was also diagnosed as having a pineal tumour. On his discharge from hospital Mr Green was placed under the Home treatment team. He remained under the Home Treatment team until 1° April 2015 at which stage he was discharged back to his GP. On his discharge from hospital there was no follow-up by a Consultant Psychiatrist nor was there any referral for treatment for his diagnosis of Post traumatic stress disorder. In July 2015 his GP made a referral to Tameside and Glossop Healthy Minds for one to one CBT. He had his first assessment on the 26" October 2015 at which stage he had a PHQ 9 score of 25 and a GAD score of 17. Due to difficulties attending and sporadic contact Mr Green was discharged from the Service. A further referral was made by his GP in May 2016 and the deceased was on a waiting list at the time he died. CORONER'S CONCERNS The concerns noted by the Court during the course of the Inquest are as follows: Pennine Care NHS Trust, Churchgate Surgery and Tameside and Glossop CCG 1. It was unclear why a referral was made to Adult General Psychiatry whilst Mr Green remained an inpatient, there was no evidence that this referral was ever considered or actioned. 2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. 3. When a referral was made this was made to Healthy Minds. The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD. 4. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted. ._ The Court heard evidence that there is a commissioning gap for the provision of services for Complex PTSD and complex presentations such as that of Mr Green. 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 | 45" frot2017 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Thomas Green. [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. 16.02.2017 Joanne Kearsley Area 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.
q = Tameside and Glossop Clinical Commissioning Group Headquarters. Dukinfield Town Hall King Street Dukinfield SK16 4LA Tel: 0161 342 5500 www.tamesideandglossopccg.org Your ref: || Date: 28 March 2017 Ms Joanne Kearsley Area Coroner Manchester South Coroners Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Kearsley, Thomas Josef Patrick Green Date of Birth: 1 November 1994 Date of Death: 10 June 2016 Thank you for your Regulation 28 report dated the 17 February 2017, and for bringing to my attention the concerns you had after hearing all the evidence in this tragic case. Your concern relevant to NHS Tameside and Glossop CCG has been reviewed, and our response is outlined below. Concern: The Court heard evidence that there is a commissioning gap for the presentation of Complex PTSD and complex presentation such as that of Mr Green. Response: Members of my team have met with staff within Pennine Care NHS Foundation Trust and identified a number of actions that require our joint attention to ensure that service improvements are made. We understand that Mr Green was a person with complex needs and that he struggled to access an appropriate service to meet his needs from local mental health services. It must have been a very frustrating experience for Mr Green and his family in trying to get help. Although we do not commission a Complex PTSD service, we do have an Individual Funding Request process, where extraordinary packages are commissioned for individuals. This would have been appropriate for Mr Green had it been used. We are committed to learning from this case and will continue to work with Pennine Care Foundation Trust, GPs and other staff working in neighbourhoods to improve patient pathways and ensure swift and easy access to more specialised support when required. The findings from a recent Healthwatch report, rich in service user experience, is also being used to extend our understanding of mental health services. Chair: Dr Alan Dow Accountable Officer: Steven Pleasant MBE NHS Tameside and Glossop Clinical Commissioning Group Headquarters: NHS Tameside and Glossop Clinical Commissioning Group, Dukinfield Town Hall, King Street, Dukinfield, SK16 4LA. Tel; 0161 342 5500 www.tamesideandglossopecg org i} * Tameside and Glossop Clinical Commissioning Group Recommendations:- 1. The CCG will clarify the Individual Funding Request process to ensure that, where required, Pennine Care staff can apply for individual funding for extraordinary care, e.g. for Complex PTSD and ensure that PC.FT staff are fully briefed about the process by 1/6/17. 2. The CCG will work with PCFT and GPs to review and establish clear pathways into MH support for people with complex needs. This will identify any gaps which will be taken forward within commissioning intentions. We have commenced this work already and aim to conclude it within four months. 3. The CCG will also seek assurance from PCFT that they deliver their action plan regarding this serious incident through our bi-monthly contract monitoring meeting. Thank you again for bringing this matter to my attention. | trust this addresses your concerns. Yours sincerely —- = Tameside & Glossop CCG Chair: Dr Alan Dow Accountable Officer: Steven Pleasant MBE NHS Tameside and Glossop Clinical Commissioning Group Headquarters: NHS Tameside and Glossop Clinical Commissioning Group, Dukinfield Town Hall King Street, Dukinfield, SK16 4LA. Tel: 0161 342 5500 www tamesideandglossopceg org
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