Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0133, written 28 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 | 28 Apr 2018 |
|---|---|
| Reference | 2018-0133 |
| Deceased | Sara Moran |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | Lancashire 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)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Philip Dunne MP,
Minister of State for Health
c/o Ministerial Correspondence and Public Enquiries Unit
Department of Health
Richmond House
79 Whitehall
London
SW1A 2NS
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
2
CORONER’S LEGAL POWERS
I 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.
3
INVESTIGATION and INQUEST
I conducted an investigation into the death of Sara Antonia MORAN, known as Sally,
and the inquest that was held over the course of two days on 9th and 10th April 2018.
The medical cause of death was 1a morphine toxicity
The conclusion of the Coroner as to the death: DRUG RELATED
In paragraph 3 of the Record of Inquest I recorded as follows:
Sara Moran, known to her family as Sally, had a history of mental health
problems and drug abuse. At approximately 1030am on Saturday 22nd April
2017 police attended at her home address after a concern was raised for her
welfare. The property was found to be secure and entry was forced. Sally had
made efforts to barricade herself into her bedroom where she was located on
her bed and in close proximity to a large number of blister packets of
medication. The last known communication with her was no later than 0730
hours on Tuesday 18th April 2017. She had most likely been deceased since at
least that afternoon. A subsequent post mortem examination confirmed she
had died from the effects of voluntarily ingesting a large quantity of morphine.
1
4
CIRCUMSTANCES OF THE DEATH
Sara had a history of mental health issues but had not been detained in a mental health
facility nor been a voluntary patient in such a facility for some time. Historically she was
known to fail to engage with mental health services and had previously been
discharged from services regularly. At the time of her death she was diagnosed with
Recurrent Depressive Disorder (F.33) and Mental & Behavioural Disorder due to
Multiple Drug Use (F.19).
On 5th April 2017 her General Practitioner, with whom she had a good relationship,
referred her for an urgent assessment of her mental health when she presented as
paranoid and at one point threatened to throw herself in front of a train A mental
health professional was able to speak to her Mother later that day and decided she
could spend the night at her Mother’s address on the understanding that she attend a
previously planned appointment for an assessment scheduled for the next day. This
was regarded as a reasonable decision. However, she did not attend and could not be
contacted.
After a Multi-Disciplinary Meeting held on 7th April 2018 she was sent a letter asking
her to contact the team if she wanted an assessment and indicating that In the event
no contact was received from her during the following ten day period she would be
discharged from mental health services and back to her GP.
On 10th April 2017 mental health services confirmed there was some contact with Sara
and arrangements were made for an appointment on 13th April 2017 but she did not
attend.
On 15th April 2017 the mental health team were contacted by the police who were with
Sara at the time and the police were concerned about leaving her on her own although
she had not expressed any suicidal intent. She would not go to hospital for assessment.
That conversation appears to have concluded on the basis that the police were under
the impression that the mental health professionals would be in contact with Sara but
the Deputy Team Leader with whom they spoke told the inquest she had understood
that Sara had expressed suicidal thought and that the police had called for an
ambulance which would take her to hospital where she would then be assessed. I
preferred the police version on this disputed piece of the evidence.
The mental health team tried to make contact with her but she again failed to engage.
There was no further contact with her. Ultimately she was reported as missing by a
concerned neighbour who had last seen her on the morning of the 18th April 2017. By
the morning of the 22nd April 2017 the police felt it necessary to force entry to her
property where she was found deceased. It was determined at the inquest that
although a letter felt to be in her handwriting was found in her property which may be
interpreted as an indication of intent to harm herself it was undated and may not have
been written around the time of her death. The criminal standard of proof was not
satisfied to the extent that the Coroner could be sure beyond a reasonable doubt Sara
intended to take her own life.
, an Investigation and
During the inquest evidence was heard from a
Learning Specialist who had performed the role of Investigation Lead as regards the
Lancashire Care NHS Foundation Trust post incident review. His evidence was
constructive. He informed the inquest that in his view at the time of the above events
2
pertaining to Sara Moran the Crisis Resolution and Home Treatment Team staff were
trying to service the needs of too many Service Users when taking into account the
numbers of staff available and that this over capacity would in his view have affected
the quality of the service afforded to Sara Moran.
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 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. Having reviewed the inquest evidence, and notably the evidence of
referred to above, I informed the court that I would write this report. I
am concerned that if mental health professionals are expected to provide care
to an excessive number of service users – many of whom inevitably pose
significant challenges – then there a genuine risk of future deaths arises as a
result of this. Sara Moran had a history of drug and mental health problems.
Although I did not find that the care afforded to Sara contributed to her fatal
outcome this does not prevent me from writing this report. If mental health
professionals are finding themselves struggling to provide the level of service
that Service Users such as Sara require then such demands in my judgement
inevitably pose a significant risk that one or more such Service Users may not
receive the level of attention they need and with potentially fatal
consequences.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I
proposed to write to the Department of Health by way of a report in accordance with the
provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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 24th June 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:
3
Family of Sara Moran
Chief Executive, Lancashire Care NHS Foundation Trust.
Chief Executive, Blackpool Council.
I 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.
9
A.A.Wilson
Alan Wilson
Senior Coroner for Blackpool & The Fylde
Dated: 28th April 2018
4
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.
From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health and Inequalities D epartm ent Department of Health and Social Care of Health aa SW1H OEU Our reference: PFD 1131236 Mr Alan Wilson HM Senior Coroner, Blackpool & Fylde Municipal Buildings Corporation St Blackpool FY1 1GB \2 June 2018 Roy JU weer Thank you for your letter of 28 April to the Minister of State for Health about the death of Ms Sara Antonia Moran. I am responding as Minister with portfolio responsibility for mental health. I have noted carefully the circumstances you have outlined around Ms Moran’s death and your concern about capacity within mental health services. I should firstly point out that individual NHS Trusts are responsible for the number and type of staff they employ and for ensuring there is a sufficiency of staff trained and competent to carry out their duties. Appropriate staffing levels are already a core element of the Care Quality Commission’s (CQC’s) registration regime underpinned by legislation. All providers of regulated activities must be registered with the CQC and meet the registration requirements. The 16 safety and quality requirements set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 include a requirement for the deployment of sufficient numbers of suitably qualified, competent, skilled and experienced persons. In July 2016, the National Quality Board published ‘Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time: Safe, sustainable and productive staffing’. This safe staffing improvement resource provides an updated set of expectations for nursing and midwifery care staffing, to : https://www.england.nhs.uk/wp-content/uploads/2013/04/nqb-guidance.pdf help NHS provider boards make local decisions that will support the delivery of high quality care for patients within the available staffing resource. NHS Improvement is leading the national programme to develop and deliver NHS safe staffing improvement resources for specific care settings, including mental health. The National Quality Board published ‘Safe, sustainable and productive staffing: An improvement resource for mental health”, in January 2018. The resource outlines a systematic approach for identifying the organisational, managerial and environmental factors that support safe staffing. It makes recommendations for monitoring and taking action if not enough staff are available to meet people’s needs. On the matter of capacity within crisis resolution and home treatment teams (CRHTTs) specifically, we do recognise that, at present, further investment and development is required to ensure that all CRHTTs are adequately resourced to be able to offer safe, therapeutic crisis assessment and home treatment. Where they are resourced and operating in line with the evidence base, the evidence base demonstrates that they are able to achieve improved outcomes and experiences for people. NHS England is committed to ensuring that by 2021 all CRHTTs are resourced to operate on a 24/7 basis, with enough staff to deliver intensive home treatment in line with the evidence base. This is being supported by new data collections to provide transparency about the large variation among clinical commissioning groups in terms of the resources they are providing to CRHTTs and other crisis and acute mental health services. Delivering the expansion of CRHTTs is critical both to alleviate the suffering of individuals in crisis, but also to alleviate pressure on acute in-patient mental health care and tackle inappropriate and expensive acute out of area placements. Further information about the delivery of this commitment can be found in ‘Jmplementing the Five Year Forward View for Mental Health’’, published in July 2016. On workforce, we acknowledge that the mental health workforce is facing pressures and this is why Health Education England (HEE), in conjunction with NHS England and NHS Improvement, published ‘Stepping Forward to 2020/21: Mental Health * https://improvement.nhs.uk/resources/safe-staffing-mental-health-services/ 3 https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf Department of Health Workforce Plan for England”, in July 2017. The mental health workforce plan is a fully-researched and considered response to the commitments made in both the ‘Five Year Forward View for Mental Health’? and ‘Future in Mind”. Working with the Royal Colleges, trainees and mental health charities, HEE will develop an urgent action plan to attract and retain more clinicians to work in mental health services and psychiatry. HEE will also commission focus groups and polls of potential and existing trainees so it can better understand the obstacles, increase the support offered to them and improve the profile and attractiveness of careers in mental health. The expansion of medical student places by 1,500 in England creates opportunities to increase the numbers of trainee psychiatrists. The mental health workforce plan commits HEE to work with the Royal College of Psychiatrists to ensure that the allocation of these places is to universities with a proven track record in producing psychiatrists. HEE also has plans to increase the exposure to psychiatry during training (which can help increase applications for the specialty). HEE has already increased the number of doctors in the Foundation Programme doing a four month psychiatry post to 50 per cent. For the longer term, the plan commits to exploring with the Medical Schools Council changing entry requirements for medical degrees so that Psychology ‘A’ level is considered of equal merit to increase the pool of applicants likely to go on to become psychiatrists. Specifically, the ‘Five Year Forward View for Mental Health’ sets the objective that Improving Access to Psychological Therapies (APT) services should see 1.5 million people a year by 2020, with 75 per cent of people accessing care within six weeks and 95 per cent within 18 weeks, with particular improvements in access for people from black and minority ethnic groups, people with a learning disability, older people, and women in the perinatal period. ‘ https://www.hee.nhs.uk/sites/default/files/documents/Stepping%20forward%20to%20202021%20- %20The%20mental%20health%20workforce%20plan%20for%20england.pdf ° https://www.england.nhs.uk/wp-content/uploads/20 1 6/02/Mental-Health-Taskforce-F YF V-final.pdf *https://assets. publishing. service. gov.uk/government/uploads/system/uploads/attachment data/file/414024/Childrens M ental _Health.pdf This will require the training of an additional 4,500 therapists between 2016 and 2020. A substantial part of this expansion will rely on a move to further integrate mental and physical health services through the development of Integrated IAPT Services. This is reflected in the ‘General Practice Forward View’’ with the objective that there will be 3,000 therapists co-located in primary care by 2020. I hope the information I have provided is helpful. Thank you for bringing your concerns to our attention. IE DOYLE-PRICE SS, f https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf
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