Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0264, written 9 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Nov 2017 |
|---|---|
| Reference | 2017-0264 |
| Deceased | Daisy French |
| Coroner | Louise Slater |
| Coroner area | South Yorkshire (West) |
| Category | Mental Health related deaths · Child Death (from 2015) |
| 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 THIS REPORT IS BEING SENT TO: 1. The Secretary of State for Health 1 CORONER Sarah Louise Slater, Assistant Coroner for South Yorkshire (West) 2 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 (Investigatory) Regulations 2013. (1) Where – a. A senior coroner has been conducting an investigation under this Part into a person’s death and c. b. Anything revealed by the investigation gives rise to concern that circumstances creating a risk or other deaths will occur, or will continue to exist, in the future, and In the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have the power to take such action. (2) A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. (3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner INVESTIGATION and INQUEST On 25th April 2017 I commenced an investigation into the death of Miss Daisy French. The investigation concluded at the end of the inquest on 8th November 2017. The conclusion of the inquest was that Miss French died from; 1a) Multiple Injuries 2) Asperger’s Syndrome A narrative conclusion was recorded as follows: Daisy French died as a result of injuries she received when she was struck by a train at Meadowhall Railway Station. Daisy deliberately placed herself in front of the train but due to her mental illness it is unclear whether she intended to take her own life at this time. 1 4 CIRCUMSTANCES OF THE DEATH Daisy was 12 years old when she was first referred to Child and Adolescent Mental Health Services (CAMHS) in January 2013 following an overdose. Daisy had several and some lengthy admissions to the Becton Centre, a specialist in-patient facility for children and young people with serious mental health issues. Daisy was diagnosed with depression, Asperger’s syndrome and non-organic psychosis. Due to the diagnosis of psychosis, Daisy’s care was to be transferred from CAMHS to the Early Intervention Service (EIT) which is an adult psychiatric service. This transition started when Daisy was 15 years of age. , Consultant Psychiatric confirmed this transfer to adult services is in accordance with national guidance but Daisy found this transition difficult and her mental health deteriorated. Daisy was restrained by British transport Police at Meadowhall Railway Station on the 29th November 2016 and the 15th March 2017 because she was trying to get on the tracks, both times she was detained under section 136 of the mental health act and taken to Maple Ward which is an adult psychiatric ward at the Northern General explained that all out of hour’s mental health services for Hospital, Sheffield. 16 year olds is provided by the adult services. Therefore, although Daisy was well known to the CAMHS and still under their care, when issues occur “out of hours” she was to be considered an adult and therefore was taken to and assessed by Adult Services. The evidence of the adult service practitioners is that they cannot access any CAMHS records and therefore could potentially go into a mental health assessment of a 16 to 18 year old “blind”. The practitioners confirmed that was problematic. Although, because Daisy was transitioning between CAMHS and Adults Services they did have access to some records because they can access all adult services records on their own system called “insight”. In addition, when Daisy’s mental health deteriorated further because she was now aged 16 years she was admitted to a Crisis House for adults rather than being able to access the CAMHS provision or support. Finally, Daisy wanted to try and live independently and a placement was arranged for her to reside in a Young Women’s Housing Project. During this placement Daisy was detained under section 136 after trying to get on to the track at Meadowhall Railway Station on the 15th March 2017. Daisy was again taken to the out of hours adult services and was assessed as not requiring detention and she was released back to the housing project where there are no staff on duty. Daisy continued to struggle with her mental health and the transition from CAMHS to adult Services. On the 19th April 2017 daisy deliberately placed herself in from of a high speed train at Meadowhall Railway Station and died as a result of the injuries she sustained. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving raise 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 MATTER OF CONCERN for the Secretary of State to consider is as follows: 1) The communication/information sharing between CAMHS and Adult Services. 2) Transition of care from CAMHS to Adult services. 2 3) Out of hour’s provision for 16 to 18 years. (During working hours they are considered children and therefore are the responsibility of CAMHS, out of hours the same individuals are considered adults and are therefore assessed by and potentially admitted to adult psychiatric units. 4) Placement of an under 18 year old in a Crisis house for adults 5) Returning an under 18 year old to a supported living setting following a mental health act assessment where no staff are on duty at the premises. The Secretary of State for Health is asked to consider whether it is appropriate for the Trust’s to review its systems and procedures in place in relation to the mental health services provisions for 16 to 18 years olds because HMAC Mrs Slater is concerned that this situation could occur again. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4th January 2018. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; 1. 2. 3. 4. 5. The parents of Daisy Sheffield Children’s Hospital Sheffield Health and Social Care Sheffield Safeguarding Children Board NHS England 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. 9 9th November 2017 Louise Slater Assistant Coroner 3
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.
ae From Jackie Doyle-Price MP Department Parliamentary Under Secretary of State for Care and Mental Health of Health 39 Victoria Street London SWIH OEU 020 7210 4850 PFD-1106353 Ms Louise Slater HM Assistant Coroner, South Yorkshire (West) 10 JAN 2018 HM Coroner’s Office The Medico-Legal Centre Watery Street Sheffield S3 7ET Veo, An Soke, Thank you for your Report dated 9 November to the Secretary of State for Health about the death of Miss Daisy French. I am responding as Minister with responsibility for mental health and I apologise for the slight delay in doing so. I was very saddened to read of the distressing circumstances surrounding Daisy’s death. Please pass my condolences to her family and loved ones. I appreciate this must be a very difficult time for them. Your Report raises a number of concerns around transitioning from children’s and young people’s to adult mental health services, and I would like to take this opportunity to explain the national position. Firstly, we are clear that providers of health and social care services should always work together and plan with the person whenever a transfer of care is taking place. The principles for a good transition are covered in guideline 43: Transition from children’s to adults’ services for young people using health or social care services, published by the National Institute for Health and Clinical Excellence (NICE) in February 2016 (www.nice.org.uk/guidance/ng43). Decisions about local health services are made at a local level and different areas of the country have adopted a range of strategies in order to ensure the right relationships and processes are in place to support effective transition locally. In order to embed proper transition planning processes across the country, NHS England introduced a national financial incentive in 2017/18 to improve young people’s experience of transition out of children’s and young people’s mental health services, under the Commissioning for Quality and Innovation (CQUIN) scheme (www.england.nhs.uk/nhs-standard-contract/cquin/cquin-17-19/). It applies to all young people transitioning through mental health services on the basis of their age and it requires both the ‘sending’ and the ‘receiving’ providers to work together with the young person to plan for the transition and set up personal goals. The CQUIN is rewarded partly on the basis of two surveys of young people, so that their feedback on experiences is central to the process. The CQUIN runs from 2017-19, after which it will be reviewed. In addition, NHS England has produced resources to support improved commissioning of specialist children’s and young people’s mental health services!. This includes a model specification on Transition from Child and Adolescent Mental Health Services’, and a sample Discharge and Transfer of Care Protocol, Also relevant here is the Transforming Children and Young People’s Mental Health Provision: a Green Paper, published in December 2017 by the Department of Health and the Department for Education, which builds on our commitments through Future in Mind. We are currently consulting on a range of measures to transform children’s and young people’s mental health services, which includes issues such as improving transition for young people who require ongoing mental health support into adulthood. We will consider the concerns you have raised as part of this consultation. However, you can respond separately to the consultation before 2 March 2018 at www.gov.uk/government/consultations/transforming-children-and-young-peoples- mental-health-provision-a-green-paper. With regard to communication and information sharing between children’s and young people’s and adult mental health services, the Health and Social Care (Safety and Quality) Act 20154 introduced a legal duty requiring health and adult social care bodies to share information where this will facilitate care for an individual. Local commissioners and providers are responsible for ensuring processes and systems support the appropriate and timely sharing of information, communication and joint working to meet the needs of people who require support. This includes mental health services. ’ https://www.england.nhs.uk/wp-content/uploads/2015/01/mod-camhs-tier-2-3-spec. pdf ? https://www.england.nhs.uk/wp-content/uploads/2015/01/mod-transt-camhs-spec.pdf 3 https://www.england.nhs.uk/wp-content/uploads/2015/01/mod-camhs-transt-prot.pdf “Health and Social Care (Safety and Quality) Act 2015 (c. 28) ae Department of Health We recognise this is particularly important at points of transition and transfer of care between services and the incentives introduced by NHS England and resources available to services to facilitate transitions described above are designed to support this. Turning to your comments with regard to out-of-hours services for 16 to 18 year olds, and crisis support, I can provide assurance that NHS England is prioritising improvements to children’s and young people’s crisis support. An additional £6.8million was made available to clinical commissioning groups (CCGs) in 2017 to support accelerated implementation of local children’s and young people’s crisis teams. As set out in Implementing the Five Year Forward View for Mental Health*>, NHS England, NICE and the National Collaborating Centre for Mental Health are developing a series of new mental health pathways to aid transformation. This includes pathways for urgent and emergency care (including children and young people) and for generic children’s and young people’s mental health, which are currently being considered for publication over the coming months. There are a wide range of service models in existence to provide crisis services to children and young people. This may include services commissioned as ‘adult services’, which provide an urgent and emergency mental health response to young people aged between 16 and 18 years, while others provide ‘all-ages’ services. NICE guidelines promote specialised care for children and young people up until their 18th birthday. Whichever model is locally commissioned to provide this service, the expectation is that they are staffed by practitioners who are trained, competent and experienced in working with children and young people with mental health difficulties. Locally commissioned services should form part of an overall crisis pathway for children and young people that details 24-hour, seven-day provision. Your Report states that Daisy was to be transferred from the CAMHS to the local EIT service, which is an adult psychiatric service. My officials have suggested that this refers to the Early Intervention in Psychosis (EIP) service. EIP services can start from age 14 and it is appropriate for young people to be referred to them. 5 https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf The Early Intervention in Psychosis Access and Waiting Time Standard, April 2016, was targeted at people aged between 14 and 65. It states that Commissioners and providers should ensure that children and young people (aged under 18) also benefit fully from the standard and that there are robust local arrangements in place between children and young people’s mental health services and EIP services so that specialist expertise in working with children and young people with psychosis is available. 1 hope this clarification is helpful. You ask whether it is appropriate for the NHS in Sheffield to review the systems and procedures in place for mental health services for 16 to 18 year olds. Where there are concerns about local health services, it is the responsibility of the local NHS organisations to review those concerns and take action as appropriate. We are clear that learning lessons where things have gone wrong is essential to ensuring the NHS provides safe, high quality care. I am informed that the NHS in Sheffield has taken a number of measures to address the concerns raised. This includes training for staff on transitions; the opening of a Section 136 suite at Sheffield Children’s Hospital; and the employment of a Mental Health Liaison Consultant to commence in January 2018. In addition, an information sharing agreement is to be drawn up between NHS organisations in Sheffield. I am advised that the Sheffield Children’s NHS Foundation Trust, the Sheffield Health and Social Care NHS Foundation Trust and the Sheffield Teaching Hospitals NHS Foundation Trust are working together to review the actions taken and will provide a response to you. Finally, I am advised that Sheffield CCG is seeking full assurance of learning across the Sheffield health system and is undertaking a safeguarding lessons learned review to highlight any further risks in the system to be addressed. This is to be completed by April 2018. The CCG will also review the commissioning of these services to ensure they are safe and fit for purpose. I hope this reply is helpful. Thank you for bringing the circumstances of Daisy’s death to our attention. JACKIE DOYLE-PRICE
esti Py Sheffield Children’s NHS INHS} Sheffield Health NHS Foundation Trust . and Social Care NHS Foundation Trust Director of Nursing & Quality: Medical Director: Dr Mike Hunter 4 January 2018 Ms Louise Slater Assistant Coroner Office of H M Coroner The Medico-legal Centre Watery Street Sheffield $3 7ET Dear Ms Slater Re: Regulation 28 Report to Prevent Future Deaths - Daisy French (Deceased) Following the Regulation 28 Report to Prevent Future Deaths issued on 9 November 2017 to the Secretary of State for Health, please find below the details of a joint response from Sheffield Health and Social Care NHS Foundation Trust (SHSC) and Sheffield Children’s NHS Foundation Trust (SC NHS FT). The Trusts also enclose a copy of a Regulation 28 Action Plan which has also been compiled as a result of the Report. The MATTERS OF CONCERN and the Trusts’ responses are as follows: 4. The communication/information sharing between CAMHS and Adult Services Current information sharing between Child and Adolescent Mental Health Services (CAMHS) and the Adult Services can and does take place via telephone calls or written letters. As CAMHS and the adult services/Trusts have different IT patient record systems, it presents a challenge for each service to be accessed by the other. Also, each Trust's fire wall and data protection governance systems prevents Sheffield Teaching Hospital’s (STH) and SHSC staff accessing CAMHS patient records (as held by SC NHS FT) and CAMHS accessing the adult Emergency Department (as held by STH) records to ascertain which CAMHS patients have recently attended the Emergency Department (ED) at STH. SC NHS FT had recognised, prior to the Coroner's verdict in the case of Daisy French, the risks around 16 and 17 year olds, known to CAMHS and presenting with Deliberate Self Harm to the ED or Sheffield Adult Liaison Service at STH in relation to access to records. CAMHS is trying to establish a pathway of data exchange between STH/ED and CAMHS but this has been problematic, due to data protection governance. SC NHS FT’s Medical Director and Chief Information Officer are working to resolve this block and enable flow of information from STH/ED to CAMHS and vice versa. It should also be noted that there has always been the 24/7 facility for SHSC and STH staff to phone the CAMHS ‘st on call (via SC NHS FT’s switch board) and ask for a verbal history of the young person presenting in the ED at STH as the CAMHS 1st on call has access to CAMHS electronic records. 2. Transition of care from CAMHS to Adult Services Whilst there was evidence of transition planning between the services, it is clear from the point of transition from children’s to adult services there was no regularly documented evidence of continued collaboration post transfer, including access to historical information held by CAMHS. We recognise how critical multi-agency collaboration is in order to safely transition a young person, to ensure that all parties are working collaboratively and in the best interests of the young person. We are strengthening the existing Transitions Protocol for 16 and 17 year olds across multiple areas, including but not exclusive to:- - Early Intervention in Psychosis; - Eating Disorders; - Community Mental Health Teams; - Hospital Liaison; - Autism Services. Inclusive of the principles of the national Commissioning for Quality and Innovation (CQUIN) goals relating to transitions and learning from transition case examples, we will ensure that the Transitions Protocol will be improved and jointly signed off by both Trusts and regularly audited. Deviation from the Transitions Protocol will be managed on a case by case basis inclusive of both Trusts. Transition lead nurses from both SC NHS FT and SHSC are working together to produce a patient journey pathway that incorporates feedback from the pre and post transition questionnaires. Preparatory events have taken place involving both Trusts in November 2017, for example a Transition workshop which involved experts by experience as well as clinicians from both Trusts/services. In addition, an event will take place on 5 January 2018 concentrating on mapping the crisis and emergency care pathways for 16 and 17 year olds, which should give more clarity on the city’s provision and highlight gaps. The Transitions Protocol has been revised through joint sessions with representation from both Trusts. Wider consultation on the Transitions Protocol is now required and the revised Protocol will be formally adopted through both trusts’ governance processes by 31 March 2018. Following joint approval, the Trusts will ensure that the process is regularly audited and action taken when process is shown to deviate. 3. Out of hour’s provision for 16 to 18 years It has been agreed that SHSC will continue to provide as necessary, assessment and treatment for under 18 year olds, out of hours. The Section 136 bed for Children & Young People is now in operation within SC NHS FT. The Sheffield Adult Liaison Service now operates 24/7, 365 days per year. This will ensure a timely response to any 16 or 17 year old presenting to the adult A&E Department. This provision will remain in place until such time as more robust commissioning and provision is in place. SC NHS FT has also recognised the gap in provision of a fully funded CAMHS Mental Health Liaison Consultant, and at cost to the Trust, has appointed into this position, so as to support the current CAMHS service and provide a point of reference around the care co-ordination of the 16 and 17year olds. SC NHS FT awaits the national publication of a CAMHS mental health liaison service specification, which will allow the city to benchmark on its current provision. SC NHS FT will work with local commissioners on the benchmarking exercise. 4. Placement of an under 18 year old in a Crisis house for adults SHSC is working with Rethink Mental Illness to develop a protocol for under 18 year olds being admitted into the adult crisis house. This is to ensure that appropriate safeguards are put in place to provide support when such a requirement arises and when it is clinically indicated that this is a better alternative to admitting under 18 year olds to an adult psychiatric ward. SHSC will offer its knowledge and expertise in developing community based alternatives, appropriate to need, to the Children’s Services. The Protocol (as referred to above) will be developed and approved through appropriate governance processes by 31 March 2018. 5. Returning an under 18 year old to a supported living setting following a mental health act assessment where no staff are on duty at the premises Following the inquest, SHSC has taken the decision to update its team’s working protocols to ensure that any young person (16-17 year old) returning home to independent or supported living receives appropriate contact within 24 hours of discharge from an A&E attendance. |n addition, the initial plan of care will identify any immediate support needs and details of crisis response services. SHSC has also identified an Operational Director Lead who will oversee transitions going forward to ensure timely action against the points identified above. Child Death Overview Panel Review Evidence was provided at the inquest that all of the matters about which the Coroner had expressed concern during the hearing would also be considered in the city wide review in which both Trusts are participating in. The Trusts also note that there is a Learning Lessons Review which is meeting 26 February 2018 and the findings from this review will be reported into the Child Death Overview Panel review. The Trusts understand that the review is due to be completed within 4 — 6 months of the inquest hearing and therefore expect the report between March - May 2018. On receipt, the Trusts will promptly action the recommendations as set out in the review which have not already been addressed following the inquest and will add to the action plan as appropriate. We hope that this response outlines a clear direction and a commitment from the two Trusts to work together to address the issues outlined in your letter. Please do contact us should you require any further information. Yours sincerely L AS Dr Mike Hunter Medical Director, SHSC Enc. Regulation 28 Action Plan
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