Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0010, written 12 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jan 2018 |
|---|---|
| Reference | 2018-0010 |
| Deceased | David Buttriss |
| Coroner | Emma Carlyon |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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 David John Buttriss deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr Phillip Confue, The Chief Executive of Cornwall Partnership Foundation Trust _——— Director of Cornwall Health 3. Chief Executive of NHS England CORONER |, Dr E Emma Carlyon am the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 An investigation was opened on 13" May 2016 into the death of DAVID JOHN BUTTRISS who died on 9" May 2016 at his home address Western Meadows, Under Lane, Launceston. An inquest was opened on 16" May 2016 and a full Inquest hearing was held between the 6-7" September 2017 at Truro Municipal Buildings. The Inquest found the cause of death as 1a Massive haemorrhage 1b Penetrative trauma to the right neck and the conclusion was “Suicide”. CIRCUMSTANCES OF THE DEATH David Buttriss had been aggressive towards his parents on the morning of the 9"" May 2016 and produced a Stanley knife at the time and was threatening to kill himself. His parents phoned the police at 10.21am. While his father was on the phone to the police David stood at the top of the stairs on the landing and said “Call them off, I’m not a danger to you or mum. They'll take me away. Don’t do this”. David then cut himself at around 10.41 am and became unconscious. Despite medical assistance and resuscitation from his father, the police and paramedics he was confirmed dead at 11.35 am. A hand written note was found in the rear of annotated book “Loving Someone with Border-Line Personality” stating “Every night is a Friday night and every morning is a Monday Morning. Love you all. So very sorry. Dave X.” He suffered from long term mental health issues which had deteriorated after he failed to rekindle a significant relationship in the weeks prior to his death. In addition the use of cannabis and the effect of an anaesthetic had adversely affected his mood. There had been input from his GP, the Community Mental Health Team and the Home Treatment team and out of Hours doctors and paramedic in order to address his deteriorating mental health. 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. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at inquest that e There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis e The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by (on 25" April nor did the mental health workers have information about the appointment with | nor were they aware of the medication issues. The Out of Hours rim” did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7" May. e _lItwas clear from the evidence of the Paramedic andi Wand the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Buttriss on the night of 7‘" May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the role of the Home Treatment Team Out of Hours provision. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation have the power to take such action. 1. To review the methods of requesting and obtaining relevant information on a patient between health agencies for the purpose of treating a patient in timely manner e.g. Patient profile requests from mental health services and mental health input summaries to GP especially at time of quick deterioration in health/mental health or crisis. 2. To review the possibility of secure health record sharing between mental health agencies, Hospitals, GP’s and out of hours health agencies e.g. Out of Hours GP, Home Treatment Teams and paramedic and Hospital Emergency Departments 3. To clarify to health professionals (and if possible to patients and public) the roles and responsibilities of each health Agencies especially outside normal working hours and weekends so that patients are referred to the correct agency and are aware of the safety nets in place if their health deteriorates 4. To consider GP’s making a routine follow up after referral or signposting to other agencies to ensure that referral has been followed up and the outcome know. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 12" March 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following interested Perscrs it iT Devon and Cornwall Cc: South West Ambulance Service. | have also sent it to nvestigating Officer of the Devon and Cornwall Police and th CIC (new Out of Hours Service) 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] [SIGNED BY CORONER] 12/01/2018 Gud alto Erovra Ge ‘Ss
3 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.
th March 20 8 018 Phil Confue e Carew House e chnology Park k Beacon Tec d Dunmere Road D N min PL31 2QN Bodm Tel: 0 3 01208 834613 n D Dr E E Carly Senior Coro S yon ner for Corn nwall and th he Isles of S Scilly By Email onl B ly ornwallcoro c oner@cornw wall.gov.uk Dear Dr Car D rlyon Regulation R 28 Report to Prevent t Future De eaths – Dav vid John Bu uttriss dec ceased write in res I w will respond aken by the ta e Trust. sponse to yo to each ma our Regulat atter of con tion 28 Rep cern as out port followin tlined in you ng the inque ur report an est of David nd detail the d Buttriss. e action tak In this lette ken and to b r I be 1. To re healt reque times eview the m th agencies ests from m s of quick de methods of s for the pu mental healt eterioration requesting urpose of tr th services n in health/m and obtain reating a p and menta mental healt ing relevan atient in a al health inp th or crisis. nt informatio timely man put summari on on a pat nner e.g. P ries to GPs tient betwee Patient Profi especially en file at The Trust ha T hat access th esignated r d dministrato a Since the im S Profile toget P as impleme to mental referral adm or requests mplementat her with the ented a new health ser ministrator a copy of t ion of the e referral. w assessme rvices is co to manage the Patient assessmen ent service r onsistent an all referra Profile from nt service s replacing th nd effective ls into Adu m the patien some GPs e Single Po e. Each lo lt Mental H nt’s GP for now routin oint of Acce ocality area Health Serv every refer nely provide ess to ensu a now has vices and th rral receive e the Patie re a he ed. ent Once the as O a ppropriaten fo ocusing on or secondar fo ssessment ness for se the formula ry services has taken p econdary m ation and re then advice place and a ental healt ecommenda e, guidance a decision th services ation of the and signpo made by th a letter is e assessme osting is offe he multi-disc sent to th ent. If the i ered. ciplinary te he patient a ndividual is am as to th and their G s not suitab he GP ble We are a research a cpn-tr.CFTresearch active trust, to get inv @nhs.net volved in a research project, please emai il For information on m mental health medica ation visit choiceandm medication.org/cornw wall Chair: Dr Barbara V Head Office: Carew Tel: 01208 834600 E Vann Chief Execu w House, Beacon Tec Email: cpn-tr.enquirie utive: Phillip Confue chnology Park, Dunm es@nhs.net mere Road, Bodmin, PL31 2QN www.co ornwallft.nhs.u uk In addition Beth Ford, in her new role as Community Mental Health Nurse Consultant, has begun working with a number of local GP practices. This has involved meeting GPs to discuss the new assessment service; the role and remit of Community Mental Health Teams and ways to improve information sharing and raising patients of concern. This is an ongoing piece of work to continue to improve liaison between services. 2. To review the possibility of secure health record sharing between mental health agencies, Hospitals, GP’s and out of hours health agencies e.g. Out of Hours GP, Home Treatment Team and paramedic and Hospital Emergency Departments The Trust already works with other agencies to allow secure health record sharing. Agencies are requested to complete an application form for access to RiO, the Trust’s electronic health record system. The application form is a standard form which requires specific information detailing the individual, their role, employing organisation and the legal basis for access as well as confirmation of Information Governance training. The Trust has allowed access to RiO to a number of agencies including Cornwall Council, acute hospitals and GPs. 3. To clarify to health professionals (and if possible to patients and public) the roles and responsibilities of each health agency especially outside normal working hours and weekends so that patients are referred to the correct agency and are aware of safety nets in place if their health deteriorates. In direct response to your Regulation 28 report the Trust has changed the Trust’s internet page. There is now a designated section headed “I need help now” providing mental health crisis information. The internet page is accessible to all members of the public including patients and health professionals and provides information explaining the roles and responsibilities of daytime and out of hours mental health services as well as details of a number of helplines and resources available to support those in crisis. Contact telephone numbers are also provided for the Trust’s Home Treatment Teams and Community Mental Health Teams. In addition new Safety Plans have been developed to be completed and provided to patients containing detailed crisis information for patients and their relatives, friends and carers. The plans confirm the name of team providing the care and the name of their care co-ordinator as well as the best number to contact the team and crisis numbers. The plan encourages carers to share any concerns and participate in the care and also explains that a “Nearest Relative” can speak to an Approved Mental Health Professional about their rights as a nearest relative. The plan is completed with the patient and sets out their warning signs; coping strategies and professionals or agencies to contact in a crisis. The Trust is reviewing the Out of Hours services and this is likely to result in changes to the Home Treatment Teams within the next 6 months. Once changes have been confirmed the Trust plans to meet with external providers to confirm the changes and clarify the role of the Home Treatment Teams. 4. To consider GP’s making a routine follow-up after referral or signposting to other agencies to ensure that referral has been followed up and the outcome known. Page 2 From the Trust’s perspective the outcome of an assessment with Adult Mental Health Services is confirmed in writing to GPs and on-going liaison work with GPs will also improve communication and information sharing. In summary action has been taken by the Trust with the introduction of the assessment service; liaison work with GPs; changes to the Trust’s internet pages and the introduction of a patient Safety Plan. The Trust already has a mechanism in place to allow access to RiO. The Trust is taking action in reviewing the Trust’s Out of Hours services and any changes will be communicated to external providers. I am truly saddened by the death of Mr Buttriss and I wish to extend my condolences to his family. Yours sincerely Phil Confue Chief Executive Page 3
Devon Doctors PUTTING PATIENTS FIRST 10 Manaton Court PRIVATE AND CONFIDENTIAL Manaton Close Dr E. E. Carlyon Matford Business Park Senior Coroner for the County of Cornwall Exeter EX2 8PF The New Lodge Admin line: 01392 822345 Newquay Road Truro www.devondoctors.co.uk TRO 9AA social Enterprise 1 March 2018 Dear Dr Carlyon Re: Regulation 28 related to Mr David Buttriss (deceased) Thank you for your letter dated 12" January 2018 requesting action relating to your Regulation 28 report, to prevent future deaths. Your letter was directed to Dr Dean Marshall, Medical Director for Cornwall Health. You are aware, as identified within your report, that Cornwall Health (a subsidiary company of Devon Doctors) no longer provide the out of hours service within Cornwall and that this is now provided by a partnership of Kernow Health CIC, Royal Cornwall Hospital NHS Trust and Vocare, under the name of Cornwall 111 Integrated Urgent Care Service. You sent a copy of the regulation 28 report to Kernow CIC and | too have passed the responsibility to review the actions you have identified for Cornwall to the new provider, having shared these with Dr Dean Marshall who, while no longer Medical Director for Cornwall Health, continues in the role of Medical Director for the new service. As Devon Doctors no longer provide any urgent care within the county of Cornwall we are unable to effect the potential changes you are seeking. However, as Devon Doctors provide the Integrated Urgent Care Service for the county of Devon the actions from your regulation 28 report have been reviewed by Dr Mark Eggleton, Medical Director. Dr Eggleton notes that some of your recommendations regarding information sharing are beyond the control of Devon Doctors but he is assured that our clinicians are able to make accurate assessments regarding risk, to the patient and others, and they have appropriate pathways to escalate their concerns to local mental health services. In reality this often means the patient is referred to ED to see the liaison psychiatrist team, since mental health assessments in the home environment are even more difficult to arrange out of hours than they are in hours, Further, Devon Integrated Urgent Care Service, in conjunction with Devon Partnership Trust, have community mental health practitioners (CMHP) working within our Clinical Assessment Providing out-of-hours medical care for the NHS across the county Devon Doctors Ltd - Company No. 05174987. Company limited by guarantee and registered in England and Wales Service, which supports direct access to mental health support for callers to urgent care with mental health issues. In addition Devon Doctors Group has had involvement with a serious incident, also related to a suicide, and for which the inquest is pending. In part as result of this case, Livewell Southwest has developed a Rapid Reassessment Pathway for individuals with mental health needs who are discharged from secondary to primary care. The pathway has been presented to, and agreed by, the Local Medical Council and provides a safety net whereby if a patient was to relapse, they could re-access psychiatric services in a timely way. | trust that this response is satisfactory. Yours sincerely Head of Governance, Patient Experience and Communications Devon Doctors Group
Dr Emma Carlyon
Senior Coroner
England = Satié
Professor Stephen Powis
National Medical Director
Skipton House
80 London Road -
SE1 6LH
The New Lodge,
Penmount,
Newquay Road,
Truro, Cornwall, JO Arpril 2018.
TR4 9AA
Dear Dr Carlyon,
Re: Report to Prevent Future Deaths (Regulation 28) following the
conclusion of the inquest into the death of David John Buttriss
Thank you for your Regulation 28 Report to Prevent Future Deaths (“Report”)
following the inquest into the death of David Buttriss. | would like to express
sincere condolences to Mr Buttriss’s family.
In your report you have asked NHS England to consider several matters of
concern to ensure to prevent future deaths.
: |
As the first two points within section 6 are concerned with information sharing we
will provide a response to both these points together.
NHS England is committed to working with the National Data Guardian to
encourage health and care practitioners to share information in the interests of
patients. There are clear guidelines that encourage information sharing such as
the principles and recommendations published in the 2013 review of information
governance in the health and care system ("To Share or Not to Share"'). This
report was conducted by Dame Fiona Caldicott who has since been appointed to
be the National Data Guardian.
There are also obligations on clinicians under the common law duty of care to
ensure that data is shared appropriately with colleagues, but much of this is
dependent on the professional judgement of clinicians. We understand that not
all data is shared as there may be circumstances in which this could be
detrimental to the health and wellbeing, however we would expect that these
incidents are documented.
We recognise that there are many challenges across the NHS to support secure
data and record sharing, and we are actively leading a number of initiatives to
address this. For example, the Global Digital Exemplar (“GDE”) programme, led
1 https://www.gov.uk/government/publications/the-information-governance-
review
High quality care for all, now and for future generations
by NHS England, will improve electronic information sharing as many parts of the
service still rely on paper-based systems. This will join up and digitise the health
systems so that clinicians have timely access to accurate patient information and
equally patients will have better access to their records too.
The GDE programme will also support digitally advanced acute and mental
health Trusts to share their learning and experiences with other NHS Trusts to
ensure they can also harness the use of digital technology and information
sharing to deliver high quality care. NHS Trusts will receive support through
funding and international partnership opportunities to become Exemplars over
the next two to three and a half years. NHS Trusts participating in the GDE
programme will also be required to support digital record-sharing with local
partners across physical and mental health. They are expected to adopt
appropriate technologies, implement standards and business processes which
will enable patient and service user information to be shared across care
settings. ‘
In addition, NHS England is working with a number of Local Health and Care
Record Exemplars to support the provision of safe integrated care across health
and care settings. The aim will be to establish a local record for authorised staff
in different organisations to access permitted information about a patient's history
of contact with the NHS and related care services. This may include information
from ‘physical health checks’ for people with serious mental illness which NHS
England is encouraging a greater take up of. We have made progress on this
with around 60 local information sharing initiatives underway, each aiming to
share information across organisations — such as GP, Acute and Social Care
settings — and across geographies as the patient moves.
With regards to the third point within section 6, NHS England has set an ambition
in the Five Year Forward View for Mental Health to ensure that community based
mental health crisis and acute services are available 24/7 everywhere by 2021,
and to expand provision of 24/7 specialist mental health services in A&E and
general hospitals.
NHS England has already published guidelines on the provision of urgent and
emergency mental health provision in A&E / general hospitals, and intends to
publish guidelines in 2018/19 to clarify the pathways of care for urgent,
emergency and acute mental health services in the community. This includes
ensuring that anyone, including health professionals, police, family members are
able to access timely, 24/7 specialist care for people with emergency mental
health needs.
With respect to point 4 within section 6, GPs, as specialists in primary care
medicine, have to manage risk and uncertainty in their day to day clinical
practice. There are established procedures in place in general practice to ensure
urgent and important referrals and actions are followed up or “safety netted” to
ensure a patient's care is not compromised by administrative failings: The Care
Quality Commission (“CQC’) as part of its inspection regime review practices
systems and processes.
High quality care for all, now and for future generations ~
The judgement when to “safety net” by arranging a follow up contact with the
patient will be a clinical one, with the clinician balancing the benefits of an earlier
review with the need to ensure the practice can provide sufficient access to other
patients with acute or urgent health problems. GP IT systems already offer
systems for GPs to use prompts and reminders for them to take an action to
ensure a patient has been contacted by appropriate specialist services.
Jn response to this Report, NHS England proposes to disseminate a reminder to
GPs to safety net urgent mental health referrals, reflecting in particular the
inherent vulnerabilities associated with patients with mental health problems who
may find it more difficult to engage with specialist mental health services when
they are acutely unwell, and furthermore consider giving a patient written
guidance on what to expect and when following a referral, given the impact
mental health problems have on concentration and hence memory.
| hope this provides you with the assurance that NHS England is responding to
the concerns raised and has taken action to improve the provision of mental
health care services to patients.
Yours sincerely,
Professor Stephen Powis
National Medical Director
NHS England
High quality care for all, now and for future generations
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