Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0231, written 6 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Sep 2017 |
|---|---|
| Reference | 2017-0231 |
| Deceased | Brandon Singh Rayat |
| Coroner | Dianne Hocking |
| Coroner area | Leicester City and South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. 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: The Rt Hon Jeremy Hunt MP, Secretary of State for Health. Chief Operating Officer, East Leicestershire and Rutland CCG 1 CORONER am Dianne Hocking Assistant Coroner, for the area of Leicester City and Leicestershire South 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 10/08/2016 I commenced an investigation into the death of Brandon Singh Rayat, aged 15 years. The investigation concluded at the end of the inquest on 31 August 2017. The conclusion of the inquest was Suicide. Brandon was discovered hanging by a scarf around his neck from a hook in his wardrobe by police who had been called to his home address on the 09 August 2016. He was taken to Leicester Royal Infirmary initially but was then transferred to the Glenfield Hospital, Leicester where he died on the 10 August 2016. He had been receiving treatment from the Child and Adolescent Mental Health Service at the time of his death for low mood and anxiety. Brandon was last seen face to face by one of the treating team on the 31 May 2016 and the final contact with him was on the 03 August 2016. Cause of Death was:- 1a) Severe Hypoxic Ischaemic Encephalopathy 1 b) Strangulation by hanging 4 CIRCUMSTANCES OF THE DEATH I n April 2105 Brandon refused to go to school and became more and more reclusive and anxious. He was taken to the GP by his mum and he was entered into the care of the Child and Adolescent Mental Health Services. He was diagnosed with low mood and anxiety and was treated with fluoxetine. His mental health continued to deteriorate and he refused to engage with any professionals tasked with trying to assist him. His mother went to his mental health appointments alone without her son and the majority of the contact with either her or Brandon was by telephone. At times she managed to get him into the car but when they arrived at the appointment he absolutely refused to get out of the car in order to see the clinician due to his anxieties. Appointments were made appropriately by health care staff but contact with him by health professionals was via occasional telephone calls, when he agreed to speak to them. The last face to face contact with any member of the health care team was on the 31 May 2016 and his suicide occurred on the 09 August 2016. It was established that the efficacy of his care was compromised because of this lack of contact but Brandon was simply too anxious to attend out patients appointments and there was no provision or funding for the clinicians to o to Brandon's home to treat him. 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In m y 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) That there is no provision of mental health care for children in Leicestershire who due to their anxiety are unable to attend hospital for treatment. There is a CRISIS team for children but I have been told that this cannot fulfil the function of long term treatment. I. ACTION SHOULD BE TAKEN I n my opinion action should be taken to prevent future deaths and I believe you 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 01 November 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. 8 COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Dr P. Miller, Chief Executive, Leicestershire Partnership NHS Trust Mr J. Adler, Chief Executive, University Hospitals Leicester NHS Trust Chief Operating Officer, Leicester City Council Sir David Behan, Chief Executive, Care Quality Commission 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. 9 [DATE] [SIGNED BY CORONER] 6t" September 2017
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.
-~ x `; '- ti ~ ~~. "" ` M ~~ ~` Our reference: PFD-10972$7 Your reference: CJEM/GA,102241-2016 Mrs Dianne Hacking HM Assistant Coroner, Leicester City and South Leicestershire, The Town Hall, Town Hall Square, Leicester, LE 1 9BG t .~,c~ .~~=s From Jackie Doyle-Prlca MP ParlFamentary Under Secretary of Sate far Care and Menta! Nealth Rlchmand House 79 Wh/tehall Londgn SW1A 2NS ozo ~z~o aaso 31 October 2017 Thank you for your letter o~6 September to the Secretary of State about the death of Master Brandon Singh Rayat. I have been asked to respond. I was. very saddened to read of the circumstances surrounding Brandon's death. Please pass my condolences to his family and loved apes. This is a truly tragic case and I appreciate this must be a very difficult time for them. Your Report raises concerns that there is no provision of mental health care for children in Leicestershire wha, due to their arixiety, are unable to attend hospital for treatment. You mention that there is a crisis team for children but that you have been informed that it cannot fait1 the function of long term treatment. This very sad case highlights the need for local services that can cater for varying needs at different paints inn the care pathway. The provision of local health services is a matter for local deterrninatian, However, I can explain,th~ work we are undertaking to transform children and young people's mental health end improve access to high quality services for all children and young people that need them. We are working with partners across the system to embed these principles sa that commissioners from across health, social care and education are able to build an improved local support offer. This work is supported by £1.4 billion of additYonal investment from 2015/16 to 2020/21. In 2015/16, local areas came together to develop joint agency Local Transformation Plans that set out the local priorities for investmenfi. These were signed off by Health and Wellbeing Boards and 123 plans were published covering the whole country. Local areas are asked each year to refresh and republish these plans. As part o~the focus to improve access aid reduce unwarranted variation i~. the quality of help, NHS England is developing a new national generic pathway for children and young people's mental health. This is expected to be published shortly. This will set out the key functions and competences that commissioners and providers should consider across the whole pathway ~- from when children and young people first seek help, to routine treatment and the support for those children and young people with more challenging and intensive needs. I am advised that the East Leicestershire and Rutland Clinical Commissioning Group (CCG) responded to you on 6 October, You will therefore be aware that the Leicester, Leicestershire and Rutland CCGs commission a range of CAMHS to meet different levels of need. This includes outpatient and community services and the recent xnfiroduction of a new Crisis and Home Treatment service that became fully operational in April 2017. The CCG confirmed that both these services are able to provide home visits and, in the case of the new Crisis and Home Treatment service, there is now a home treatment team dedicated to undertaking home treatment. Learning lessons where things have gone wrong is essential to ensuring the N~IS provides safe, high quality care. The CCG has provided assurance that the death of Brandon was subject ko a Serious Incident investigation by'the Leicestershire Partnership NHS Foundation Trust, as well as amulti-agency case review commissioned by the Leicester City Safeguarding Board. An improvement plan will be put in place with appropriate monitoring by the CCG, Trust and Safeguarding Board: I hops this information is helpful, Thank you for bringing the circumstances of Brandon's death to our attentian,r.:-~~~-~- JAC D4YLE-PRICE
1 ~ f l~= East Leicestershire and Rutland Clinical Commissioning Group From the office of: Telephone:0116 2956224 Email address: Our ref: COB-SH-065 Your ref: CEM/GA/02241-2016 6th October 2017 HM Coroner For Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester LE1 9BG , Chief Nurse &Quality Officer/Deputy MD CCG Headquarters Leicestershire County Council Room G30, Pen Lloyd Building County Hall, Glenfield Leicester LE3 8TB Web: vwvw.eastleicestershireandrutlandccg.nhs.uk LEICL< TAR CITI' SOUTFI LEICESTERSHIRE CORONEK.`; DISTRICT 1 1 0(; ( 2017 Dear Mrs Hocking RE: Brandon Singh RAYAT Thank you for your letter dated 6 September 2017 with regard to your concerns raised during the inquest for Brandon Singh RAYAT which were; There is no provision of mental health care for children in Leicestershire who due to their anxiety are unable to attend hospital for treatment. There is a CRISIS team for children but 1 have been told that this cannot fulfil the function of long term treatment The Leicester, Leicestershire and Rutland Clinical Commissioning Groups (LLR CCGs) commission a range of Children and Adolescent Mental Health services (CAMHs) to meet different levels of need, which is led by Leicester City CCG, our lead commissioner. These include an outpatient and community service that has been operational for over 6 years and last year, in April 2016, the new Crisis and Home Treatment service was introduced and has been fully operational since April 2017. Both of these services are able to provide home visits and can carry out care and/or treatment which may include welfare visits to families and children, assessment of need and risk and an offer of support and interventions as appropriate. The new Crisis and Home Treatment service enables professionals to engage with a young person and gain a greater understanding of the individuals' behaviour and mood as well as family and home circumstances; there is now a home treatment team dedicated to undertaking home treatment. We are cognisant of the fact that the current CAMHs outpatient and community service specification, implemented in April 2015, requires a systematic review and update to reflect the new services and that have been implemented, for example the alignment of CAHMs to the liaison service in the new Emergency Department and new `place of safety' at the Bradgate Unit as well as the Crisis and Home Treatment service. This pathway and contract review has commenced. Managing Director: Mrs Karen English Chairman: Dr Richard Palin The death of Brandon has been subject to a Serious Incident investigation by the Trust and also Multi-agency case review commissioned by the Leicester City Safeguarding Board (LSCB); further lessons learnt will inform the development of an improvement action plan and those actions that pertain the Trust will be monitored via the CCG and LPT Clinical Quality Review Group (CQRG) and the LSCB. At this time we are, as confident as we can be, that we are commissioning a full range of services, however we acknowledge that we may need to amend the service specification in response to the contract reviews that are taking place and continue to work in partnership with the provider to understand the challenges they face in delivering care. trust that I have been able to provide assurance that we are taking this matter seriously and that we are taking action to address the concerns raised. If there is any further information you require, please do not hesitate to let me know. Yours Sincerely U~ Chief Nurse &Quality Officer /Deputy Managing Director On Behalf of English Managing Director cc. , Managing Director, West Leicestershire CCG , Managing Director, Leicester City CCG
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