Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0071, written 17 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Mar 2017 |
|---|---|
| Reference | 2017-0071 |
| Deceased | Stephen McDermott |
| Coroner | Claire Hammond |
| Coroner area | Preston and West Lancashire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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. Heather Thierney-Moore, Chief Executive, Lancashire Care Foundation Trust
1 | CORONER
lam Miss Claire Hammond, Area Coroner, for the coroner area of Preston and West
Lancashire.
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 26 May 2015 | commenced an investigation into the death of Stephen McDermott, 32
years of age. The investigation concluded at the end of an inquest on 2 March 2017,
after hearing evidence on 1 and 2 March 2017. The medical cause of death was 1a
hanging and my conclusion at the end of the inquest was suicide.
4 | CIRCUMSTANCES OF THE DEATH
Stephen McDermott was found deceased by his mother on 25 May 2015 at his home
address where he had died sometime earlier as a result of the intentional application of
a ligature,
Of relevance to the Regulation 28 Report is that over a four-month period prior to his
death Mr McDermott had presented at Accident and Emergency at Chorley and South
Ribble District and General Hospital on three occasions (16.2.15, 23.3.15, 6.4.15),
having overdosed on drugs and alcohol and twice having been recovered from the train
tracks. On each occasion he was assessed by a member of the mental health liaison
team from Lancashire Care Foundation Trust [‘LCFT’] and discharged without any
follow-up from mental heath services, the view being taken that the issue was one of
substance misuse and that there was no immediate suicide risk.
In addition, on 16 March 2015, Mr McDermott’s General Practitioner contacted the
Single Point of Access Team ['SPOA’] by telephone to request a mental health
assessment, so concerned was he about Mr McDermott’s deteriorating state of mind.
Again, no referral was made for follow-up with mental health services, the view being
taken that the issue was one of substance misuse (the inquest found that there was no
assessment of suicide risk during that telephone call).
Further, on 1 April 2015 Mr McDermott’s mother contacted the SPOA to advise that in
her view Mr McDermott was in crisis, at risk of suicide and had written a suicide note.
Although a face-to-face appointment was organised for him in 8 days’ time, it was
subsequently cancelled, and when Mr McDermott attended for it he was turned away
without being seen.
The inquest heard independent expert evidence from consultant
psychiatrist, who made a number of criticisms of the level of care provided to Mr
McDermott by LCFT and of the record keeping systems in place, staff training and the
standard of the Trust's ‘Team Incident Review.’ She was of the view, and the senior trust
witnesses accepted (consultant psychiatrist and leader author of the
Team Incident Review) and EJ Service Manager for adult mental health
services), that there had been missed opportunities to attempt to facilitate treatment.
Although | did not conclude that these issues caused or contributed to the death, it is my
opinion that their existence means there is a risk that future deaths will occur unless
action is taken.
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) The electronic record system is not the same across all mental health teams
(Single Point of Access, Crisis Team, Mindsmatter) meaning that not all relevant
records were available at each point of assessment of Mr McDermott —
Mindsmatter use ‘IAPTS’ and the other teams use ‘ECR Blue’ as opposed to
there being one record system for all to use and to ensure mental health records
are in one place. Although HE gave evidence that Mindsmatter now has
access to ECR Blue and the other teams have access to IAPTS, his evidence
was that the system remains “clunky.” His evidence was that a new electronic
system has been commissioned, but he did not know whether it was one system
for all teams to have access to and/or whether the problems highlighted in this
case would remain. In addition, the system is not due to be implemented for a
further 18 months. He agreed that having one electronic system used by all
teams would be of benefit;
2) In addition to the problems highlighted above of not having all records on one
system, there was evidence of poor use of the records that were available
resulting in liaison nurses who were assessing Mr McDermott having an
incomplete picture:
a) During the GP’s telephone call a: the Single Point of
Access team on 16 March 2015, did not check the full records
to learn the background of Mr McDermott’s recent admission following
an overdose;
b) During her assessment of Mr McDermott on 27 March 2015, m7
mental health liaison nurse, was only aware that Mr
McDermott had taken an overdose of drugs and alcohol. She was
unaware that Mr McDermott had been brought to Accident and
Emergency whilst intoxicated having been located near the train station
by police and having reported to them that he was having thoughts of
jumping in front of a train, a fact that was readily available in the
records;
c) ing his assessment of Mr McDermott on 6 April 2015, |
ee ee health liaison nurse, discharged Mr McDermott without a
plan for referral into the crisis team for assessment. Part of his rationale
for this was that Mr McDermott told him he had an appointment with
3)
4)
5)
6)
7)
Mindsmatter on 9 April. This was incorrect (this date was in fact due to
the be the first face-to-face appointment with the SPOA, which was
subsequently cancelled) and demonstrates that {J either did not
have access to or did not properly check relevant records;
There was evidence of poor training with regards to incomplete assessments
and poor record keeping. In respect of the telephone call from the GP to
Ht the SPOA on 16 March 2015, there is no evidence in the records to
evidence that asked any questions regarding Mr McDermott’s mental
health, despite the fact that the GP was requesting referral into services for a
mental health assessment. There is no evidence that [MD followed the
‘Storm’ guidance (guidance that had not been disclosed at the inquest) to
assess suicide risk factors or mental health issues. His evidence was that he
would have asked the relevant questions but just did not document the
responses, but | found on the balance of probabilities that the questions had not
been asked;
Following on from the above, of particular concern was that HS line
manager, (the Access and Treatment Team Deputy Manager)
said in evidence that negative answers to questions would not necessarily
always be documented. IEEE the independent expert, and I
ee] all agreed that the records should always be a complete picture with
recording of negative answers being an essential part of that;
Mr McDermott's problems were repeatedly treated as substance misuse issues
without any consideration or assessment of whether mental health issues might
be the underlying cause of the substance misuse issues. Individuals assessing
Mr McDermott repeatedly had their views clouded by substance misuse issues,
which prevented Mr McDermott from being referred into mental health services
for assessment. Although the Trust's ‘Team Incident Review’ ['TIR’] identified
that a “more flexible approach” was required in relation to overlapping substance
misuse and mental health issues, there was no evidence at the inquest that trust
policies or procedures have changed in this respect, nor any evidence of staff
being trained to approach such cases differently;
Following a telephone call made to the SPOA by Mr McDermott’s mother on 1
April 2015, in which she advised that she feared he was at risk of suicide and
had written a suicide note, contact was made with Mr McDermott who confirmed
he could keep himself safe so an appointment was made for him to have a face-
to-face assessment at the SPOA on 9 April 2015. However, this appointment
was cancelled by the SPOA team on 7 April because Mr McDermott had been
assessed by EEE on 6 April following his attendance at Accident and
Emergency. The SPOA considered that to assess him on 9 April would be a
duplication. The expert's view, with vic rr agreed,
was that this was a missed opportunity to have a face-to-face assessment of Mr
McDermott in a non-crisis situation;
It was apparent that when patients are assessed and treated by other services,
in this case Discover Drug and Alcohol Recovery Services provided by Greater
Manchester West NHS Foundation Trust ['GMW’], LCFT do not have access to
GMW records and vice versa. In a case such as this, where there is a significant
overlap between mental health issues and substance misuse issues, it is of
significant concern that services do not / cannot share information to assist in
their assessment processes to ensure that they are in possession of the full
picture of an individual’s presentation;
8) Although LCFT instigated a ‘Team Incident Review,’ the inquest found that it
was incomplete in some important respects, most notably in that it made no
reference whatsoever to the telephone call from the GP to a: 16
March 2015, an incident which | found was the real trigger point at which Mr
McDermott ought to have been referred into services. Further, the TIR fails to
address, adequately or at all, a number of the concerns raised in this Regulation
28 report. Since the purpose of a TIR to investigate a death to identify areas of
concern with a view to learning lessons, it is a substantial concern that the TIR
was incomplete in several respects;
9) Although re accepted that a number of issues had been highlighted by
the inquest that he would be “feeding back" and “learning lessons from,” it is a
significant concern that almost two years have elapsed since Mr McDermott's
death and lessons have not yet been learned, especially since the Trust had
been in possession of the expert's report for over 3 months prior to the inquest.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | 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 15 May 2017. I, the Area 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, = (vir
McDermott’s parents), (Chief Officer Chorley and South Ribble CCG), the
Care Quality Commission and Beverley Humphrey (Chief Executive GMW),.
lam 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.
[DATE] 17 March 2017 [SIGNED BY CORONER]
SST
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