Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0277, written 16 Aug 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 Aug 2017 |
|---|---|
| Reference | 2017-0277 |
| Deceased | Christopher Fairhurst |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Community health care and emergency services related deaths |
| Organisation named | Pennine Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health, London CORONER I am Ms L Hashmi, Area Coronerfor the Coroner area of Manchester North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, ofthe Coroner’s and Justice Act2009 and Regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 2th4 May 2017 (case concluded on the 1th1 August 2017), I commenced an investigation into the death ofChristopher Ian Fairhurst. 4 CIRCUMSTANCES OF DEATH The deceased was aged just26 atthe time of his death. Against a backdrop of an episode of impulsive self-harm in 2015, depression and a more recent diagnosis of adult Attention Deficit Hyperactivity Disorder (ADHD), the deceased was found on a footpath near Spotland Bridge, Rochdale on the 5th December 2016. Empty alcohol bottles and paracetamol packets were found in the immediate vicinity. He had last been seen by his family on the 3rd December 2016 and was subsequently reported to police as a missing person at 06:30 on the 5th December 2016. Initial enquiries were conducted however the deceased was found by members of the public at around 12:35 on the date of his death before any further steps could be taken by police to find him. Treatment for adult ADHD (namely, longer acting Methylphenidate) had been appropriately prescribed on or around the 8th November 2016. There was no causal connection made, on the evidence heard, between the medication prescribed and the deceased’s actions. The evidence did not demonstrate, to the required legal standard, the necessary intent to reach a conclusion that the deceased took his own life. Conclusion: Misadventure 5 CORONER’S CONCERNS During the course ofthe 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 reportto you. The MATTERS OF CONCERN are as follows:- Nationally: 1. There is a shortage of General Practitioners (GPs) as a result of recruitment and retention problems. Surgeries are working with only 50% (or less) of their required establishment. This puts patients at risk and places unmanageable workloads upon those GPs who are in post. 2. As a consequence of 1 above, many surgeries are heavily reliant upon locum GPs. For patients this brings about a lack of continuity of care, putting patient safety at risk. 3. In order to meet ever increasing demand and to reduce delays in accessibility, GPs are being forced to adopt alternative systems such as telephone consultations (upwards of 50 per day; this is over and above all other aspects of their job) rather than face to face appointments, offering patients appointments with other health care professionals rather than a doctor etc. Further, the average appointment with a doctor where an appointment is secured has decreased as a direct — — consequence of demand and is currently an average of 7.5 minutes per patient. This is insufficient in most cases and wholly inadequate in others e.g. where the patient has a complex medical history or mental health problems. Offering double or treble appointments does not solve this problem as it reduces the number of appointments available for others. 4. Patients frequently find themselves held in long telephone queues when trying to get appointments. When they eventually get through (often after half an hour or so of waiting), they are told that all appointments for that day have already gone. When they ring the following day, the situation is repeated. Patients often give up or spend days trying before they eventually get a GP appointment. At peak times (Monday/Friday mornings) surgeries can have as many as 300 incoming calls first thing. 5. GP training GP trainees currently undertake a 3 year training programme. The overall view of - the profession is that this is inadequate and ought to be no less than 5 years in order to ensure safe standards of care in general practice. By virtue of their role, GPs require high calibre, ‘across the board’ training in a significant number of specialities. The concept of a 5-year training programme is supported by the Royal College of GPs. Whilst I recognise that a longer training programme may result in a short term reduction in the number of doctors qualified/available for appointment, in the longer term doctors will be better qualified and more able to care for patients with increasingly complex health needs/problems. 6. Both adult and children’s Autism and ADHD/ADD Psychiatric and Psychology services are currently struggling to cope with increasing demand for this area of mental health/neurodevelopmental care provision. The ‘threshold’ for referral and/or treatment has therefore been intentionally increased in order to try and address the problem. I am concerned that this is unsafe. It reduces patient accessibility to specialist diagnosis, care and treatment and places further burden upon GPs to care for patients with complex conditions. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 the 1th2 October 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 mustexplain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the ChiefCoroner and to the following Interested Persons namely: • The deceased’sfamily • The Deceased’s GP • Rochdale/Bury/Oldham CCGs • Royal College ofGPs • Royal College of Psychiatrists • Pennine Care NHS Foundation Trust • Learning and Assessment Centre (LANC UK), Horsham ( ) I am also under a duty to send the Chief Coroner a copy ofyour response. The Chief Coroner may publish either or both in a complete or redacted or summary from. 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: 16tAugust2017 Signed:
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