Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0402, written 16 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 | 16 Nov 2017 |
|---|---|
| Reference | 2017-0402 |
| Deceased | John Haines |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 2. NHS England, Manchester 3. Chief Executives of Bury, Rochdale and Oldham Clinical Commissioning Groups 4. Chief Executive, Pennine Care NHS Foundation Trust CORONER I am Ms L Hashmi, Area Coroner for the Coroner area of Manchester North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 2l June 2017, I commenced an investigation into the death of John Haines. 4 CIRCUMSTANCES OF DEATH Against a backdrop ofa sudden and unexplained onset of anxiety and depression in December 2016, the deceased had been under the care of the community mental health team/Home TreatmentTeam and his GP until the 17th March 2017, whereupon his mental health had deteriorated to such a degree that he could no longer be safely managed within the community. He was therefore admitted to a mental health ward as a voluntary in-patient. He was diagnosed with and treated for anxiety and depression. During the course ofthis admission he was seen by three different Consultants, the last ofwhich opined that he was suffering from a psychotic episode and delusional thoughts. Whilst earlier identification ofthis symptomatology may have resulted in the revision and implementation of different treatment sooner, it would not have materially altered the outcome. Following medication review by the third Consultant, the deceased’s condition improved and after a successful period of home leave, he was discharged on the 14th June 2017 with planned follow-up by the Home TreatmentTeam and Early Intervention Team. On the 15th June 2017 the Home TreatmentTeam contacted the deceased by telephone and arrangements were made to visit him. When the team attended as planned on the 17th June 2017, there was no answer at the deceased’s home address. Family subsequently tried to contact the deceased, to no avail. A concern for welfare was raised. Police attended and forced entry. The deceased was found in his bedroom. The fact of his death was confirmed by attending Paramedics at around 19:18 hours the same day. The thrust ofthe evidence suggested that the deceased had been actively making plans to end his life prior to discharge from hospital, despite reassurances to the contrary. The mechanism used was in keeping with this and the circumstances in which the deceased was found. 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: 1. During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist, despite the fact that this has been raised in previous Regulation 28 PFD Forms. Notably, all clinicians were of the professional view that psychological therapy was critical to treatment, alongside psychiatric care. 2. Similarly, patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (HTT’) etc. The only way for patients to get access to a Psychologist is through referral to ‘Healthy Minds’. Health Minds cannot provide access where the patient remains under the care ofthe HTT etc. 3. Timely access to Healthy Minds is also hindered by long waiting times. I understand that the provision of Psychology services is entirely a matter for Commissioners. 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 the 1jth 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 namely: The deceased’sfamily - The British Psychological Society (for information only) - Care Quality Commission (for information only) - I am also undera 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 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: 1th6 November2017 Signed:
1 response 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.
(ece &IV6 Fi’i:l Heywood, Middleton and Rochdale Clinical Commissioning Group Postal address: NI-IS HMR CCG P0 Box 100 Rochdale 0L16 9NP Location address: NumberOne Riverside Smith Street Rochdale Lancashire 0L16 IXLJ Tel: 01706652203 hrcçgsafeguardinjinhsnet Response in relation to the death ofJohn Haines and subsequent Reciulation 28 1. During the course of treatment it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist, despite the fact it had been raised in previous Regulation 28 PFD forms: HMR CCG acknowledges the statement above In the period 2016-2017 there was investment from HMR CCG as part of the safer staffing initiative. These monies were allocated and autonomy given to the wards as to how they were spent based on need and existing and establishments. Bury has some Psychological therapy provision on the inpatient wards and HMR have recruited a qualified Psychologists to deliver therapy in the inpatient setting. The decision was reached after analysis of the services provided and where the gaps in staffing were. In Oldham however this analysis reached a different conclusion particularly in relation to acuity and complexity and the monies were allocated to provide band 2 staff and increase the administration function thus freeing up qualified staffto deliver treatment. This was based on the theory that fundamental ward staffing levels needed to be at an optimum level to ensure service delivery is of a high standard. At the current time the provision across all inpatient services is being looked at by the provider to ensure equitable provision for service users and staffing establishments that meet the safer staffing expectations (due to be had Winter 2017). These staffing establishments will be developed using the Nationally agreed safer staffing tool and review of sustainability within current budgets. In addition the Provider has advised the CCG that it is working to the CQC minimum quality standard offer. 2. Similarly patients cannot access a qualified psychologistwhilst under the care of the Home Treatment Team (HTT) etc the only way a patient can get access to a psychologist is via referral to Healthy Minds. Healthy Minds cannot provide access where the patient remains under the care of HTT etc: This statement is true. However consideration needs to be given to the level of engagementwhich can be afforded by a patient with enduring mental health issues in a crisis to the service offered by Healthy Minds. This service would offer intervention for less severe and non-urgent mental health issues. With regards to the Home Treatment Team (HTT), the provider has an ongoing workstream in place regarding baselining current service provision against core fidelity requirements. This workstream is aligned to a broader Crisis and Acute Pathway workstream across provider and commissioner, and will support and inform locality developments including ‘Out of Hospital’ approaches. The ideal would be to keep and treat individuals within the community and to identify and meet their needs including psychology. 3. Timely access to Healthy Minds is hindered by long waiting times: The National standards are as follows - • 75% of people access treatment within six weeks. • 95% within 18 weeks. Waiting times for Healthy Minds in Oldham are detailed below: • Between 93.2 and 98.2% of patients are seen (referral to treatment within 6 weeks) • Between 99.1 and 100% of patients are seen (referral to treatment within 18 weeks) • The average wait in weeks from referral to 1st appointment, in June 2017 was 2 weeks, current wait (November 17) is 1.4 weeks Indicators for HMR are detailed below Indicator 2016117 Year End Q1 17118 Average IAPT 6 week finished 79 82% 91.36% IAPT 6 week first 90.68% 71.67% IAPT 18 week finished 98.38% 98.77% IAPT 18 week first 99.14% 98.89% The CCG commissioned a new Primary Care Mental Health Pathway during 2016/17, which mobilised in May 2017. The model has been developed to respond to the local population needs, preparing service users to access therapy in order to optimise recovery performance. The service is subject to robust a performance dependent payment framework which provides assurance of performance delivery. Karen Hurley Deputy Chief Officer and Executive Nurse Heywood, Middleton and Rochdale Clinical Commissioning Group
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