Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0106, written 16 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Apr 2018 |
|---|---|
| Reference | 2018-0106 |
| Deceased | Karen Edgar |
| Coroner | David Roberts |
| Coroner area | Cumbria |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Cumbria Partnership NHS Foundation Trust |
| 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.
] REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: 1. Cumbria Partnership NHS Foundation Trust (the Trust). 2. North
Cumbria Clinical Commissioning Group. 3. Morecambe Bay Clinical Commissioning Group. 4. Secretary
L of State for Health and Social Care.
CORONER
lam Mr David Llewelyn Roberts Senior Coroner for County of Cumbria
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/S/paragraph/7
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made
T INVESTIGATION and INQUEST
On 12" April 2017 1 commenced an investigation into the death of Karen Jane Edgar. The investigation
| concluded at the end of the inquest on 13th April 2018. The conclusion of the inquest was Karen was
suffering from emotional and behavioural issues and was referred to Child and Adolescent Mental Health
Services (CAMHS) in October 2015, aged 15. Her first substantive meeting with her mental health
| practitioner was on 8th February, 2016, when family work was planned. She did not start individual
talking therapy until 7thApril. Family therapy had ceased to be available. After only one more 1:1 session
on 25th April she was, on Sth May, seen by a psychiatrist who prescribed fluoxetine-10mg. In July it was
increased to 20mg. On 29th September she took an overdose of paracetamol, then raised the alarm and
received inpatient general hospital attention. Her true intention was not clear. The psychiatrist changed
her medication to sertraline SOmg which commenced on about 7th March 2017, after only twelve 1:1
sessions. On 22nd March she was involved in an outburst at school relating to her boyfriend, from whom
she had split in February. At the 1:1 on 29th March she was angry and upset and later that day
researched ‘suicide note’ on the internet. Sertraline was increased to 100mg on 30th March. She had
convinced herself she was pregnant and told her former boyfriend on 1st April. She admitted to a friend
having tried to hang herself. On the evening of 7th April she had an angry exchange with her former
boyfriend over the pregnancy issue via text and went home. Whist her parents were not in the house she
hanging herself from a dressing gown cord in a wardrobe in her bedroom. She was discovered soon
afterwards, but despite medical treatment did not recover and was pronounced dead at West
Cumberland Hospital at 01.10 hours on 8th April. She had made a cut in the ligature with a pair of
scissors.
Medical cause: Hanging.
Conclusion: Misadventure; she hanged herself as a gesture intending to be discovered.
IE
CIRCUMSTANCES OF THE DEATH
Karen had been displaying behavioural and anger problems for many months when there was a major
incident in August 2015 which resulted in her and her parents seeking help. Despite a referral to CAMHS
in October 2015 assessment appointments did not take place until early December and January. Family
work was proposed but only two meetings took place before it ceased to be available. Karen did not start
1:1 work until April 2016, nearly six months from first seeing her GP. She only had 13 talking sessions
from the first assessment in December 2015 until her death in April 2017. The psychiatrist diagnosed her
with moderately severe depressive disorder and prescribed antidepressants after only two 1:1 sessions.
(NICE suggests 4-6 sessions), She was not monitored closely on four drug changes. It remains an open
question as to whether the introduction of sertraline a month before is implicated in her death. Whilst
the mental health worker did her level best it seems that the resources were inadequate to support
Karen and she received sub-optimal care. The Trust’s own report revealed a long list of failings including:-
no care plan; lack of ‘packages of care’; gaps in work force and skills base; absence of family therapy;
failure to re-assess risk formally; lack of Multi-disciplinary Meetings; absence of holistic approach and not
, engaging more productively with her school. Many of these issues were themes found to be endemic in
the Trust by the CQC in its report of 26" January 2018.
5
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 wilt 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 provision of mental health services for children and young people in Cumbria is underfunded.
(2) There are long delays in getting treatment.
(3) Failure to provide for these young people means they risk entering adulthood with unresolved
mental health issues.
{4) Lives are lost and damaged; including the effect on families as a whole.
{5} The financial cost to the state of such deaths is huge; 4 paramedics attended as did an out of hours
doctor; at least 11 police staff; hospital staff; A&E consultant; Local Safeguarding processes, costs of
inquests and Trust’s legal representation etc. all of which would be better spent on prevention.
| (6) Itis likely that any of these problems are replicated across the country hence the reference to the
| Secretary for State.
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 12"
June 2018. 1, 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
and to the CUMBRIA LOCAL SAFEGUARDING BOARD (as the deceased was under
18.. | have also sent it t , CQC, Self Harm Awareness for All Cumbria (Charity), Office of the
Children’s Commissioner, Head Master Workington Academy, the Press. who may find it useful or of
interest.
lam 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.
16/04/2018
Nand ca. “ate
Ors acave David Llewelyn Roberts Senior Coroner County of Cumbria
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.
g From Jackie Doyie-Price MP Department Parliamentary Under Secretary of State for Mental Health and Inequalities of Health & Department of Health and Social Care . 39 Victoria Street Social Care London SWIH OEU Your reference: 31479 Our reference: PFD 1129071 Mr David LI. Roberts HM Senior Coroner, County of Cumbria The Coroner’s Court Fairfield Station Street Cockermouth Cumbria CA13 9PT 14 June 2018 Thank you for your letter of 16 April to the Secretary of State for Health and Social Care about the death of Miss Karen Jane Edgar. I am responding as Minister with portfolio responsibility for mental health and I am grateful for the additional time in which to do so. I would first like to explain that the commissioning of mental health services in Cumbria is a matter for the local NHS. I note that you have issued your report to local commissioners, the North Cumbria and the Morecambe Bay Clinical Commissioning Groups (CCGs), as well as the Cumbria Partnership NHS Foundation trust, and I hope their response will be helpful. I am advised by local commissioners that they acknowledged that service provision for children and young people with emotional mental health and wellbeing problems needed to be increased, and in the last eighteen months, there has been considerable investment made to services. This has included service improvements for example, to the enhanced crisis service, the development of a community-based eating disorder service, earlier intervention services, preventative work and mental health promotion. I am further advised that local commissioners acknowledge that there have continued to be delays in referrals for therapy, including family therapy, and that there are challenges with recruiting the specialist workforce, both medical and nursing. The Cumbria Transformation Plan’, sets out how the local health system will improve the quality of access and care in mental health services for children and young people, and I understand, continues to be refined according to local need. Your report makes the point that many of the failings identified in the care and treatment provided to Miss Edgar were resonant in the publication of the Care Quality Commission’s (CQC’s) inspection report early this year’. This is, of course, concerning and we are clear that the Cumbria Partnership NHS Foundation Trust, and its commissioners, must take action to ensure the provision of high quality, safe, sustainable care. I am informed that local commissioners are working with the Trust to develop commissioning intentions for children’s and adult mental health services that include the consideration of strategic partnerships with the Northumberland Tyne and Wear NHS Foundation Trust and the Lancashire Care NHS Foundation Trust with the aim to deliver more sustainable and robust services. I am also assured that the CCGs are working to implement an action plan to address the issues raised in your Report. At a national level, I would like to assure you that improving the quality of access and care in mental health services for children and young people is a key priority for this Government, as set out in Future in Mind’, the Five Year Forward View for Mental Health‘, and, most recently, the Green Paper on transforming children and young people’s mental health services’. We are committed to ensuring our children and young people, and their families, get the support they need at the right time. The Government is already making an additional £1.4 billion available, which includes £150 million for eating disorders, to improve mental health services for children and young people with mental health problems. Ml i locuments/policies/cumbria-local-transformation- plan----cyp-ewmh-refresh-180224--final.pdf 2 http://www.cac.org.uk/provider/RNN u https://www.gov.uk/governmenv publications/improving-mental-health-services-for-young-people 6 https://www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a- preen-paper ae Department of Health & Social Care The Green Paper includes plans to improve access to services and mental health support in schools including: e Incentivising every school and college to identify and train a senior designated mental health lead to improve prevention work; e Creating brand new mental health support teams working directly with schools and colleges; and e Piloting a new four week waiting time for NHS children and young people’s mental health services. Additional funding of over £300 million will be made available post consultation. The consultation closed on 2 March 2018 and we are currently finalising the response to the consultation, which will be published in due course. Furthermore, NHS England has developed a major service transformation programme, Children and Young People Improving Access to Psychological Therapies’, to significantly reshape the way services for children and young people are commissioned and delivered. This includes, in partnership with Health Education England, the training of existing staff to deliver evidence based interventions. As part of the programme, services in Cumbria receive outreach service development support from the training provider to embed the principles of collaborative, evidence- based and outcome-focused care across all teams and services delivering care (NHS, local authority and voluntary sector). In addition, NHS England has invested in the children and young people’s Mental Health Improvement Team (MHIT) which consists of one national team and a local team in each clinical network. The MHIT provides local support to individual and groups of CCGs, Sustainability Transformation Programmes and Integrated Children’s Systems which support the implementation of national policy into local delivery. On the matter of funding for mental health services, I would like to point out that spending on mental health has gone up faster than overall NHS funding and is set to continue to rise. Spending on mental health is planned to have increased to a record £11.86 billion in 2017/18. § hteps://www.england.nhs.uk/mental-health/cyp/iapt/ ae Department of Health & Social Care The recently published NHS planning guidance’ states that all CCGs must meet the Mental Health Investment Standard (MHIS) which requires all CCGs to increase their mental health expenditure. We have introduced much greater transparency about mental health expenditure. The Mental Health Five Year Forward View Dashboard’, available online, provides detailed breakdown on spend, including by individual CCGs, for the past two financial years. I hope the information I have provided is helpful. Thank you for bringing your concems to our attention, Jacl JACKIE DOYLE-PRICE
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