Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0173, written 7 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jun 2018 |
|---|---|
| Reference | 2018-0173 |
| Deceased | Marcus Hance |
| Coroner | Guy Davies |
| Coroner area | Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Cornwall 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Officer NHS Kernow Clinical Commissioning Group, St Austell, Cornwall 2. Philip Confue Chief Executive Cornwall Partnership NHS Foundation Trust 1 | CORONER lam Guy Davies, Her Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly 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. 3 | INVESTIGATION and INQUEST On 27" October 2017 | commenced an investigation into the death of Marcus HANCE. The investigation concluded at the end of the inquest on 31% May 2018. The conclusion of the inquest was as follows Marcus HANCE died on 13th October 2017 at The Queens Head Inn, North Street, St Austell from the synergistic effect of a reckless overdose of illicit and therapeutic drugs, within the context of a history of drug abuse. My conclusion as to the death is that it was Drug Related. 4 | CIRCUMSTANCES OF THE DEATH Marcus Hance was found dead at his home address from a reckless overdose of illicit and therapeutic drugs, including amphetamine and heroin. Marcus had a complex medical history which included a diagnosis of borderline personality disorder and a history of drug abuse. This was characterised as a dual diagnosis, namely a personality disorder and drug dependency. The evidence from the Cornwall Partnership NHS Foundation Trust (CPT) concerned the role of the Mental Health Services. This included Community Mental Health Team (CMHT) assessments which revealed a long history of mental health difficulties and a diagnosis of Borderline Personality Disorder. The CPT conclusion on a number of repeat referrals was that the drug dependency should be addressed before any mental health treatment could proceed. On the occasion that the deceased was referred to CMHT, Marcus was discharged following two instances of non-attendance at CMHT appointments. Addaction provided care and treatment from 2013 to 2017 in an attempt to deal with the drug dependency. The only real engagement was from March 2017 but was problematic and progress was not sustained. The work by Addaction did not involve any measures to address the mental health issues, but was focused upon addressing the drug abuse. Marcus continued to abuse drugs up until his death. 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) Marcus was in a position where he was getting support with his drug dependency from the drug and alcohol team but was not able to access support for the mental health issues which were associated with the drug dependency. (2) The approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed. (3) The discharge from CMHT on failing to attend two appointments. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action, namely (1) To review the commissioning of services to support individuals who have drug and alcohol dependency and associated complex mental health issues. (2) To review whether drug and alcohol agencies should have the support of relevant mental health professionals to address issues of dual diagnosis, and for appropriate referring pathways and assessments within these agencies to ensure the appropriate support is being provided to increase the prospects of rehabilitation. (3) A review generally of the current pathway and provision for persons with dual diagnosis. (4) To review whether a joint approach can be facilitated by mental health services and by drug and alcohol dependency services in cases of dual diagnosis. (5) To review the approach taken in cases of non-attendance at mental health appointments, and whether attempts to contact service users should be undertaken, or alternatively to involve the police if there are concerns for the individual’s welfare. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2™ August 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 | have also sent it to the following persons who may find it useful or of interest. Operations Director, Addaction. , Co-coordinator, Cornwall drug action team. 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. 7™ june 2018 Guy Davies Lady
PRIVATE AND CONFIDENTIAL Mr Davies Cornwall Coroners’ Service The New Lodge Penmount INHS i, @) Kernow = 88 Clinical Commissioning Group Jackie Pendleton Chief Officer Sedgemoor Centre Priory Road St Austell Newquay Road Cornwall 1 August 2018 Dear Mr Davies, Thank you for your regulation 28 report to prevent future deaths pertaining to Marcus Hance. In your report you identify a number of concerns and the action to be taken by NHS Kernow Clinical Commissioning Group (NHSK) as commissioners of mental health services and the action that should be taken, The concerns you expressed were that; 1. Mr Hance was in a position where he was getting support for his alcoho! dependency but not able to access long term psychological support. 2. The approach to cases of dual diagnosis, that substance misuse should be addressed before mental health treatment could take place 3. The discharge from CMHT on failing to attend two appointments. Therefore the action NHS Kernow should take was; e Toreview the commissioning of services to support individuals who have drug and alcohol dependency and associated complex mental health issues. e To review whether drug and alcohol agencies should have the support of relevant health professionals to address the issues of dual diagnosis and for appropriate referring pathways and assessments within these agencies to ensure appropriate support is provided to increase prospects of rehabilitation e A review generally of the current pathway and provision for people with dual diagnosis. Chair: Dr lain Chorlton Chief Officer: Jackie Pendleton Head office: 01726 627800 kecg.contactus@nhs.net www.kernowccg.nhs.uk o0e00 Sedgemoor Centre, Priory Road, St Austell, Cornwall, PL25 5AS /nhskernow e To review the approach taken in cases of non-attendance at mental health appointments, and whether attempts to contact service users should be undertaken or alternatively to involve the police if there are concerns for the individuals welfare.. NHS Kernow are partners in the implementation of the existing Dual Diagnosis Strategy, along with DAAT commissioners and Cornwall Partnership NHS Foundation Trust. The strategy requires that at an operational and clinical level, services work together to ensure safe and seamless care for individual’s most affected. The Crisis Care Concordat multi-agency group, Chaired by the GP Clinical Lead for Mental Health, includes representation from the Drug and Alcohol Action Team (DAAT), and is reviewing its local action plans with a view to setting out revised actions associated with Dual Diagnosis. Cornwall Council are lead commissioners of drug and alcohol services, and there is a joint commitment to establish meaningful, equitable and sustainable service change and promote joint working across agencies. NHS Kernow are reviewing interdependencies between Outlook SW and Cornwall Partnership NHS Foundation Trust. This work includes a joint refresh of existing protocols in support of smooth referral pathways and transitions between services and different service lines, a review of risk management processes and information sharing arrangements. The intention is to conclude this work by December 2018. NHS Kernow and Cornwall Partnership NHS Foundation Trust have agreed to commence a formalised process to review a number of service specifications which will prioritise those services currently subject to transformation. This will include the approach taken in cases of non-attendance at mental health appointments, This action will be led by the Mental Health commissioning team and will commence over the summer and will be expected to be completed by December 2018. Cornwall Partnership NHS Foundation Trust's progress will be reported monthly via the integrated assurance meeting hosted by NHS Kernow with overall assurance reported to NHS Kernow’s Quality and Performance Committee NHS Kernow recognises the value of sharing the learning from serious incidents to the wider health community. The quality team will share the learning and associated actions related to this incident with our partners in Devon, Somerset and Dorset via our Community of Practice and with NHS England and NHS Improvement through our Quality Network. | hope this action provides you with some comfort. Please do not hesitate to contact me if you require anything further in relation to this case. Yours sincerely Li tbh (LE Jackie Pendleton Chief Officer Page 2
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.
NHS) Cornwall Partnership NHS Foundation Trust Phil Confue Carew House Beacon Technology Park Dunmere Road Bodmin PL31 2QN Tel: 01208 834613 11" September 2018 Mr Guy Davies Assistant Coroner for Cornwall and the Isles of Scilly By Email only cornwallcoroner@cornwall.gov.uk Dear Mr Davies Regulation 28 Report to Prevent Future Deaths - Marcus Hance deceased | write in response to your Regulation 28 Report following the inquest of Marcus Hance. Thank you for providing me with the response provided by NHS Kernow Clinical Commissioning Group, commissioners of mental health services, confirming the on-going review in relation to the Dual Diagnosis strategy; the review of the interdependencies between Outlook Southwest and the Trust and the review of a number of service specifications between NHS Kernow and the Trust. | fully endorse the response provided by NHS Kernow and confirm the Trust will be working in partnership with NHS Kernow as outlined in their response. | hope this provides reassurance around the action being taken. | wish to extend my condolences to Mr Hance’s family. Yours sincerely. Phil Confue Chief Executive ah Bh en, , We are a research aclive trust, to get involved in a research project, please email opn-\,CFTresearch@ahs.nel MINDFUL a For information on mental health medication visit choiceandmedication.org/cornwall E M P LOYE R Chair: Or Barbara Vann ~— Chief Executive: Phillip Confue Head Office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN Wifianh k www.cornwallinns. ul Tel: 01208 834600 Email: cpn-tr.enquiries@nhs.net
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