Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0208, written 27 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jun 2017 |
|---|---|
| Reference | 2017-0208 |
| Deceased | Dean Rowland |
| Coroner | Margaret Jones |
| Coroner area | Staffordshire (South) |
| Category | Community health care and emergency services related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | South Staffordshire and Shropshire Healthcare NHS Foundation Trust |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Senior Partner, Peel Medical Practice, Tamworth, Staffordshire 2. South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Stafford, Staffordshire CORONER | am Mrs Margaret Joy Jones Assistant Coroner for the Coroner area of Staffordshire South. 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 27 March 2017 | commenced an investigation into the death of Dean Mark Rowland, 27 years of age. The investigation concluded at the end of the inquest on 27 June 2017. The conclusion of the inquest was suicide. CIRCUMSTANCES OF THE DEATH The deceased had a history of two recent previous self-harm attempts. He had been depressed due to his domestic situation. His GP had treated him with sertraline and he was referred to the Community Mental Health Team. A mental health assessment on the 19th August 2016 identified that he was coping and that no special risk prevention was required. He was discharged back to his GP on the 25th August 2016. On the 21st March 2017 family had been unable to contact him and so visited his home address at iS Tamworth. He was found hanging from the bannister and death was certified at the scene at 11.00 hours. He had left a note indicating his intention to take his own life. There was no third party involvement. 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 deceased wished to discuss an increase in his antidepressant medication with a doctor. He was unable to get an appointment or speak to a GP on the telephone for nine days. (2) He was referred to a community mental health team having made two serious previous suicide attempts. He was discharged after only one consultation with no follow up plan other than for him to refer back to primary care. The family perceived he would have benefitted from a further appointment. He was very willing to engage with services. 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 23 August 2017. |, the Assistant 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. | have also sent it to members of the family who may find it useful or of interest. | 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. Date: 27 June 2017 Signed: Mids Margaret Joy Jones Assistant Coroner Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 Fax No: 01785 276128 www.staffordshire.gov.uk sscor@staffordshire.gov.uk
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.
Peel Court \ 2 Aldergate | Tamworth / Staffordshire B79 7D] Tel: 01827 50575 Fax: 01827 31891] At July 2017 Ms M J Jones Assistant Coroner Her Majesty’s Coroner Staffordshire (South) Coroner's Jurisdiction Coroner's Office No | Staffordshire Place Stafford ST16 2LP Dear Ms jones RE: Dean Rowland (Deceased) Thank you for your letter dated 28 June 2017 regarding this patient. The specific area of concern with regards to the practice*to improve access for patients to have an appointment or telephone call with a Doctor sooner than a routine appointment if they so required. We have instituted a duty doctor and telephone triage system in the practice. If the patient attends or phones the practice requesting an appointment they are told when the next routine appointment is available for the doctor of their choice and for any doctor. If they feel they need to be seen that day or that their condition will not wait until the next available routine appointment they are offered a “callback”. They will be called as soon as possible by one of the duty team who will either deal with the problem over the telephone or make them an appointment that day to see a doctor or a nurse practitioner - whichever is the most appropriate for the problem. This means that everyone who needs to be seen will be seen on the same day. | hope this provides information you require and satisfies your concerns Yours sincerely
INHS) South Staffordshire and Shropshire Healthcare NHS Foundation Trust Neil Carr Chief Executive Trust Headquarters St George’s Hospital Corporation Street Stafford ST16 3SR Tel: 01785 257888 Margaret J Jones onan Coroner oroner’s Office Ne 1 Staffordshire Place tafford ST16 2LP 15" August 2017 Dear Ms Jones e: Dean Rowland (deceased eport to Prevent Future Deaths Thank you for your letter dated 28". June 2017, reporting concerns to us, in accordance with Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. Following discussions within the Mental Health Division, | am now in a position to respond to your specific concern, which were as follows: In respect of point 2. He was referred to a community mental health team having made two serious previous suicide attempts. He was discharged after only one consultation with no follow up plan other than for him to refer back to primary care. The family perceive he would have benefitted from a further appointment. He was very willing to engage with services. Prior to his referral to South Staffordshire and Shropshire Foundation Trust (SSSFT) in me 2016 Mr Rowland was not known to mental health services, although as you report ad taken two overdoses in the preceding four months due to difficulty in coming to terms With the end of his marriage. It was immediately following the second overdose that he as referred to mental health services, beginning with an assessment from the Crisis esolution and Home Treatment Team (CRHTT) who felt a more detailed assessment rom the Community Mental Health Team (CMHT) would be of benefit; this assessment ‘ook place on 19" August 2016, 18 days after the referral, with one episode of telephone tontact in between in order to arrange the appointment. This is in keeping with expected referral timeframes for a CMHT assessment. Notably, the appointment letter also invited Mr Rowland to bring a friend or relative with him to the appointment, thereby considering the needs of carers, although Mr Rowland opted to attend alone. When seen on 19" August 2016, Mr Rowland had moved to Birmingham in order to reside with his mother, and described improvements in his mental health due to this change of environment and a now amicable relationship with his ex-wife and access to his children. Mr Rowland described his wellbeing "feel like | have my life back and am like my old self" and reported various self-help methods such as exercise and making time for himself. Importantly he expressed no further ideas of suicide. A Patient Health Questionnaire 9 (PHQ-9) was completed as part of the assessment; this is a 9-item questionnaire to explore current symptoms of depression, yielding a score of between 0 and 27. Mr Rowland scored 8, which is indicative of mild depression that would not usually require treatment; scores of 15 and above are usually seen in individuals requiring the input of a CMHT. Mr Rowland’s recent suicidal ideation and behaviour was noted, but given his current wellbeing he was deemed at low risk for further self-harm or suicide. Information was discussed on 25" August 2016 at a CMHT multidisciplinary team meeting and owing CMHT. to the information gathered in the assessment; Mr Rowland was discharged from the Mr Rowland engaged fully in his assessment and coproduced the plan which was later communicated to him by letter. He felt that the difficulties in his mental health had improved and that he did not require input from the CMHT, but was aware that he could be rereferred at any time should this situation change. The letter validated his efforts to be well and detailed online self-help resources to support these efforts, and also recommended that he register with a GP in Birmingham if he wished to continue to reside there, so that he could be referred quickly to his local mental health services in future he CMHT, this would have been transferred to the service in Birmingham local to Mr ho Cl the need arise. If the assessment had highlighted the need for ongoing input from owland’s new residence, but as described it was not required. alk Satisfied that the CMHT conducted a sufficiently detailed assessment of Mr owland’s needs, and with him arrived at the right decision at that time, namely to discharge him from the service. Following discharge | am satisfied that all communication with Mr Rowland detailed resources that he could access to support his recovery, and etailed points of contact with the CMHT should he move back to the area, and invited his deta appropriate advice to register with a GP local to his new address. The letter P to rerefer him at any time should the need have arisen. The option to involve his family in the assessment was offered but declined by Mr Rowland. I|hope this response helps to address your concerns. However if you require any further information please do not hesitate to contact me Yours sincerely @8ey Positively Differen *, s re
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