Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0240, written 26 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jul 2018 |
|---|---|
| Reference | 2018-0240 |
| Deceased | Daniel Young |
| Coroner | Shirley Radcliffe |
| Coroner area | London Inner (West) |
| Category | Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO Rt Hon Matt Hancock MP Secretary of State for Health Department of Health and Social Care 39 Victoria Street London SW1H OEU 1 | CORONER lam Shirley Radcliffe, Assistant Coroner for the coroner area of Inner West 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. 3 | INVESTIGATION On 5th February 2016 | opened an inquest into the death of Daniel Young, then aged 30 years. The inquest concluded on 28" and 29" June 2018. The conclusion of the inquest was a narrative conclusion, the medical cause of death was shock and haemorrhage due to stab wound to the abdomen. 4 | CIRCUMSTANCES OF THE DEATH 1. Daniel Young was a fit and healthy university lecturer. On 19" January 2016, he was randomly attacked on his way to work. He sustained a fatal stab wound to the abdomen. 2. His attacker (ML) had been a patient of local mental health services. He had suffered from periods of psychosis. He was known to be aggressive when psychotic. 3. At the time of the attack, ML was living in the community with no secondary mental health follow up. He had been discharged to his GP and told to remain on his antipsychotic medication for at least 6 months and only reduce them slowly, if at all. He was told that stopping the medication may lead to a relapse of his psychosis. 4. ML stopped his antipsychotics soon after discharge from the CMHT. 5. Atthe criminal trial ML was found guilty of manslaughter by reason of diminished responsibility. 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 could occur unless action is taken. The MATTERS OF CONCERN are as follows. — 1. When ML was discharged to the care of his GP by the Community Mental Health team, he was warned not to stop his medication because of the risk of relapse. 2. GP surgeries do not routinely monitor that psychiatric patients are collecting their antipsychotics. Evidence revealed that it is not uncommon for such patients stop their medication and relapse. Relapse puts them at a risk of harm to themselves and, sometimes, they pose a risk to others. 3. Following the death of Mr Young, the GP responsible for the care of ML has implemented a system within the practice to monitor the collection of antipsychotic medication of their patients. This is funded by the practice. 4. lattach a copy of the Protocol for Monitoring Collection of Antipsychotic Prescriptions. 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 24 September 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 Persons : Parents of Daniel Young (address known to the court) | 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. 26" July 2018 Dr Shirley Radcliffe, HM Assistant Coroner for Inner West London, Westminster Coroner’s Court, 65, Horseferry Road, London. SW1P 2ED i | |
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.
a From Jackie Doyle-Price MP D e p artm ent Parliamentary Under Secretary of State for Mental Health and Inequalities Department of Health and Social Care of Health & 39 Victoria Street i London Social Care SW1H OEU Our reference: PFD 1143538 Dr Shirley Radcliffe HM Assistant Coroner, Inner West London Westminster Coroner’s Court 65 Horseferry Road London SWIP 2ED \2 September 2018 deov Ve ” Thank you for your letter of 26 July to the Secretary of State for Health and Social Care about the death of Mr Daniel Young. I am responding as Minister with portfolio responsibility for Mental Health. I have noted carefully the concerns in your report. My officials have made enquiries with NHS England on these matters. You will be interested to know that NHS England is currently developing a framework for community mental health services which will articulate models of improved joint working between primary and secondary mental health services in community settings. This will support teams to work together to plan a patients’ care holistically and ensure that any transitions between settings and different teams can be facilitated with the relevant professionals having ready access to all relevant information. This is particularly important for people transitioning between service settings, for whom medication reviews need to be followed up. In addition, I am advised that the framework will set out quality benchmarks and recommendations for local systems, reflecting current evidence and existing guidance published by the National Institute for Health and Care Excellence (NICE), to support commissioners and providers across the health and care system to model and implement the framework. It will include key considerations regarding medication adherence and medicines optimisation. To support improved care coordination in the community, the framework will set out the key competencies and skills that staff from different professional backgrounds will need in order to support people they care for, and to link with other professionals and services to ensure all of a person’s needs are met. The framework will recognise needs that require special attention, such as support from a community or specialist mental health pharmacist to discuss medication choices and compliance. The community framework will also include examples of best practice information, including evidence-based community discharge processes. These will specifically reference the importance of considering a person’s discharge destination and ongoing care needs and communicating with relevant teams to ensure that the necessary support is put in place in a timely manner to enable smooth transition. In the interim, NHS England has confirmed that it will undertake the following actions by the end of the year to address the issues noted in your report: e NHS England will write to GP practices to make them aware of this issue and to consider what mechanism they do or could employ to monitor the collection of antipsychotic medication prescriptions; e NHS England will explore with NHS Digital what opportunities there are for primary care clinical systems to alert GPs around prescription collection issues for named patients and named drugs; and e NHS England will work with NHS Improvement on a communication to providers around making discharge letters explicit on medication risks that need to be monitored in primary care. I hope this response is helpful. Thank you for bringing your concerns to our attention. E DOYLE-PRICE
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