Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0090, written 27 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Mar 2018 |
|---|---|
| Reference | 2018-0090 |
| Deceased | Maureen Campbell-Scott |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
Eastern Area of Greater London Coroners MISS N PERSAUD SENIOR CORONER Walthamstow Coroner's Court Queens Road Walthamstow E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REF:6555 27th March 2018 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr John Brouder, Chief Executive, North East London Foundation Trust HR Practice Manager, Fullwell Cross Medical Centre 1 CORONER | am Miss N Persaud Senior Coroner for Eastern Area of Greater London 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 18/07/2017, | commenced an investigation into the death of Maureen Anne CAMPBELL-SCOTT. The investigation concluded at the end of the inquest 26th March 2018. The conclusion of the inquest was a narrative conclusion: Maureen Campbell-Scott suffered fatal injuries when she fell from the ledge of the Exchange Shopping Centre. She died as a result of her own actions, but the evidence does not reveal her intention at the time of the fall. 4 CIRCUMSTANCES OF THE DEATH Maureen Campbell-Scott had suffered for many years from depression and anxiety. She suffered a decline in her mental state in around April 2016. The GP referred her to the mental health services on 29 April 2016. There was a delay in the correct team processing the referral. She was assessed by the older age mental health team in September 2016, but was not considered to meet the criteria for specialist mental health services at that time. She came under the care of the specialist mental health services in November 2016 following her husband’s contact with Mental Health Direct. She remained under the care of the specialist mental health services until she passed away. Medication that she had remained stable on for many years, appeared no longer to be working for her. Her medication regime was therefore changed by her consultant psychiatrist. There were some delays in communicating requested medication changes to the GP. Directions provided by the mental health team to the GP, in relation to prescription of mental health medication were not fully complied with. It is not possible to determine whether the poor prescribing and delayed communication contributed to her death. On the 16 June 2017, Maureen climbed over the wall of the Exchange Shopping Centre car park and lay down on a ledge which was approximately fifty feet high. She had placed a plastic bag over her head. When a member of the public and members of staff from the shopping centre attempted to help her, she was seen to roll off the ledge. She died as a result of multiple injuries. Her life was pronounced extinct by a paramedic on scene at 20.19 on 16 June 2017. 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) The GP had sent the referral to the wrong team of the mental health trust. The referral then got lost between the receiving team and the correct team (the older age mental health team). This resulted in a 4 month delay in Maureen Campbell-Scott receiving an assessment. 2) There were often delays (in excess of 14 days) in the delivery to the GP of clinic letters from the mental health trust. Often, the clinic letters contained requests for the GP to make changes to medication. 3) The prescribing by the GP did not always follow the direction given by the psychiatric team. 4) In times of acute mental health crisis, medication is often rapidly changed/supplemented. Mrs Campbell-Scott had 7 changes in her medication regime between 21 November 2016 to 23 February 2017. It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist team. 5) At the time of the Inquest hearing, there had been no joint meeting between the mental health trust and the GP practice to consider the best way forward in terms of referrals to the service; prescribing during times of dynamic medication changes and general communication between the GP and the psychiatrist. 6) It is accepted that the concerns in this case are unlikely to be restricted to the Fullwell Cross Surgery. f a joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 May 2018. |, 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 persons (son). | have also sent it to Mathew Cole (Director of Public Health) and to the CQC, who may find it useful or of interest. lam also under a duty to send the Chief Coroner a copy of your response. | will also forward your response to those listed above. 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. 27/03/2018 Signature Miss N Persaud Sentor Coroner Eastern Area of Greater London
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.
Best care by the best people Ms Nadia Persaud The Coroners Court Queens Road Walthamstow E17 8QP Coroners @walthamforest.gov.uk NeLet Wa NHS Foundation Trust Trust Head Office West Wing CEME Centre Marsh Way Rainham RM13 8GQ Tel: 0300 555 1298 Dear Ms Persaud RE: Regulation 28 in the case of MC-S, NELFT and Fullwell Cross Medical Centre | refer to the Regulation 28 dated 28" March 2018 in relation to the sad death of Maureen Campbell-Scott. Please note that NELFT have been liaising with colleagues from both, Fullwell Cross Medical Centre and Redbridge CCG in regards to the action plan to address the issues raised in the Regulation 28 report. We have made good progress in regards to completion of the actions and there remain only two actions yet to be completed by NELFT alone. | have attached the latest version of the action plan for your information. | understand that [ Fullwell Cross Practice Manager, has also returned the action plan to you to evidence progress, which NELFT are grateful for. We understand that he has made a note on the action plan regarding there yet to be an agreement between Primary Care colleagues and NELFT Psychiatrists in regards to prescribing of medication changes and titration of drugs. We have had two meetings with the Fullwell Cross Practice and believe that we had agreed a process regarding the prescribing of medication to our shared patients. It was only on Tuesday of this week that we were informed that the practice had some late reservations about this specific aspect of the joint action plan. As such we are reconvening a meeting with Primary Care Colleagues to discuss the position further and agree a way forward. We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following: © Risks to patient safety. The GP has the overview of the entire patient’s medication. If the mental health medication is prescribed in isolation there is a significant patient safety risk. Medications may have interactions and contraindication that we as potential prescribers may be unaware of as we do not have an overview. e Due to advanced frailty of many of the patients, they cannot get their own prescription or do not have family members who are able to do it for them. NELFT do not have arrangements with community pharmacists to ensure medication is provided. e Many patients under the Older Adult Mental Health Team do not have capacity; therefore prescribing via FP10 is not feasible. e Many of our patients use compliance aids like dosett box/blister packs therefore the medication needs to be organised via the GP. NELFT are unable to facilitate this via local pharmacists. e Many of our patients are in care homes, nursing homes and sheltered accommodation who will not accept a prescription via the FP10, as this would need to be filled by a community pharmacist. Chair: Joe Fielder Chief executive: John Brouder E33 disability 69 confident EMPLOYER www.nelft.nhs.uk We have already agreed to provide personal contact details of NELFT Consultant’s to GPs for additional support and this action is already in place to allow GP’s to access advice regarding the management of people who have mental health problems. NELFT attended a very successful event with all Redbridge GP’s last week, where our staff did a series of table presentation to the GP’s. The theme was around mental health services and the crisis care pathway. We believe this will aid our future joint working with GP’s within the borough. The event was coordinated by EB who is the BHR CCG Lead GP for Mental Health. At the event he briefed GP’s regarding future communication methods and that all communication will move to being electronic in line with the action plan in relation to this regulation 28. | apologise for the slight delay in forwarding the action plan, but as stated above this was due to the concerns raised by the practice. You may be assured that as an organisation NELFT and our officers will not leave the matter here, but continue to do all that we can to ensure that the gap in responsibility is closed. Yours sincerely i John Brouder Chief Executive Office Ref: Joint NELFT / Fullwell Cross Medical Centre Action Plan Action Plan Title: Nadia Persaud Regulation 28 from Her Majesty’s Coroner Eastern Area of Greater London Start Date: 11-04-2018 Action Plan Owner: NELFT and Fullwell Cross Priority: Low Medium High Medical Practice Service/Team: Mental Health Redbridge and GP Target Date: 23-05-2018 Business Unit: Mental Health Directorate: Redbridge, Havering and Barking & Dagenham Source: Her Majesty’s Coroner, Eastern Area of Greater London - Hearing Serious Incident Summary of the overall Action Plan: Regulation 28 from Her Majesty’s Coroner Eastern Area of Greater London — Nadia Persaud following the death of MC-S a service user of Older Adults Community Mental Health Team Redbridge - Older Adults Home Treatment Team Redbridge and Fullwell Cross Medical Practice Recommendation Action | Action By By Progress/comments no Whom When The GP had sent the referral to | 1a GP Action Andrew 30/04/18 | Completed the wrong team of the mental NELFT referral forms on GP clinical Watson health trust. The referral then system to be separated in to different age (Practice got lost between the receiving categories. Manager) team and the correct team (older age mental health team). [4b NELFT Action NELFT | 18/05/18 | Completed This resulted in a 4 month delay All referrals into NELFT will be processed, Bob | in Maureen Campbell-Scott if the referral is sent to the wrong team Edwards - receiving an assessment NELFT will ensure the referral goes to the ICD for Regulation 28 action plan 1b.msg correct team within 2 working days. Redbridge NELFT Integrated Care Director has sent an email to all service managers, senior administrators and administrators with the instruction that referrals will be followed through until the correct * To check tick boxes, right click on box, select properties then tick check or unchecked. team has confirmed that they have Page lof5 Version 1 received it. There were often delays (in 2a NELFT Action NELFT | 18/05/18 | Completed excess of 14 days) in the All correspondence to be sent via email. Dr Shweta delivery to the GP of clinic Subject of emails to be patient NHS Anand — letters from the mental health number and patient initials. & Maria emai from Dr Anand to Consukants and trust. Often, the clinic letters Thorn Dr Shweta Anand — Associate contained requests for the GP. Assistant Medical Director, Redbridge to to made changes to medication Director send an email to all Doctors to ensure this practice is adopted. Dr Maria Thorn Assistant Director, Redbridge to send an email to all service managers and leads to ensure this practice is adopted. 2b NELFT Action NELFT 18/05/18 | Completed Medication changes to be emailed to GP Dr Shweta within 24 working hours. Anand emai from Dr Anand to Consukants and Dr Shweta Anand — Associate Medical Director, Redbridge to send an email to all Doctors to ensure this practice is adopted. 2c NELFT Action NELFT 18/05/18 | Completed All Doctors to add their telephone number | Dr Shweta Mw to the bottom of ‘change of medication Anand — notification’ emai from Dr Anand to Consukants and Dr Shweta Anand — Associate Medical Director, Redbridge to send an email to all Doctors to ensure this practice is adopted. 2d CCG Action CCG 18/05/18 GP alert system to be re-activated * To check tick boxes, right click on box, select properties then tick check or unchecked. Page 2 of 5 Version 1 2e Action for ALL Email communication to be adopted by NELFT and GP’s. This action to be communicated to all Redbridge GP's and Mental Health Services at ‘Protected learning event’ on 16"" May 2018 All 16/05/18 Completed This action was announced at a protected learning event attended by all Redbridge GPs and NELFT services on 16" May 2018 The prescribing by the GP did not always follow the direction given by the psychiatric team. 3a GP Action Only clinicians to add medication to the repeat list, medication when first initiated or dosage change should only be authorised for 1 month at a time. All Clinical staff 05/03/18 In Place 3b GP Action When medication is being stepped up or stepped down, this should only be added to the acute list and the original repeat removed from the repeat list. All Clinical staff 05/03/18 3c GP Action Any new medication changes received in writing from the Mental Health Team, will require the patient to have a consultation with a GP to ensure they have understood the regime/changes that have been made. All Clinical staff 05/03/18 3d GP Action Telephone requests for medication whether it be a repeat request from a patient or change in medication from secondary care is to stop. (Special exception for housebound patients) All Clinical staff 05/03/18 In times of acute mental health crisis, medication is often rapidly changed / supplemented. Mrs Campbell- 4a NELFT Action All NELFT Doctors to ensure that they add their NELFT mobile telephone numbers to NELFT Dr Shweta 18/05/18 * To check tick boxes, right click on box, select properties then tick check or unchecked. In Place In Place In Place bl email from Dr Anand to Consukants and Page 3 of 5 Version 1 Email correspondence from Dr Shweta Anand AMD to all Redbridge Doctors to ensure this practice is adopted. Email correspondence from Maria Thorn to all Redbridge service managers to ensure this practice This action will be completed by the end of May 2018. List being compiled and then phone numbers to be sent to email addresses of all GP surgeries within Redbridge This action will be completed by the end of May 2018. List being compiled and then phone numbers to be sent to email addresses of all GP surgeries within Redbridge Scott had 7 changes in her the bottom of ‘change of medication Anand, medication regime between 21 notification’ Maria November 2016 to 23 February Thorn 2017. Itis challenging for GP’s Assistant to be able to ensure rapid and Di accurate changes when irector medication changes are directed by the specialist team is adopted. Completed 4b NELFT Action Maria 30/05/18 A list of Consultant Psychiatrist NELFT Thorn AD telephone numbers to be re-distributed to | g pr Raj all GP's, ensuring they have the option of Kumar contacting the prescribing clinician. 4c NELFT Action Dr Shweta | 30/05/18 NELFT will provide Doctors Medical Anand, Secretaries direct number to GP’s. Maria ; Thorn If a Doctor is on leave, a colleague Aaspiaat number will be made available. Sst Director At the time of the Inquest 5a GP /NELFT Action GP 11/04/18 | Completed hearing, there had been no joint Meeting between NELFT and Fullwell NELFT | 09/05/18 meeting between the mental health trust and the GP practice to consider the best way forward in terms of referrals to the service: prescribing during Cross Surgery was arranged and attended on 11th April 2018 Follow-up meeting was held on 9" May 2018. Completed and further follow-up meetings to be arranged. * To check tick boxes, right click on box, select properties then tick check or unchecked. Page 4 of 5 Version 1 times of dynamic medication changes and general communication between the GP and the psychiatrist In attendance Senior Managers NELFT, Consultant Psychiatrists NELFT, Jacqui Himbury CCG. Dr Raj Kumar, BHR clinical lead for mental health. Andrew Watson, Practice manager, Fullwell Cross surgery Partners, GP’s from Fullwell Cross Surgery. Dr Anil Mehta It is accepted that the concerns in this case are unlikely to be restricted to the Fullwell Cross Surgery. If a joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices. 6a NELFT Action To roll out good practices as above with all Commissioned Boroughs Barking & Dagenham, Havering and Waltham Forest NELFT CCG Dr Raj Kumar 18/05/18 Dr Raj Kumar (BHR clinical lead for mental health) attended the meeting of the 9" May 2018 and is committed to working with NELFT and the CCG to roll out improved practice within Barking, Havering and Redbridge, BHR * To check tick boxes, right click on box, select properties then tick check or unchecked. Page 5 of 5 Version 1
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