Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0312, written 25 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Oct 2018 |
|---|---|
| Reference | 2018-0312 |
| Deceased | David Sargeant |
| Coroner | Guy Davies |
| Coroner area | Cornwall & the Isles of Scilly |
| Category | Alcohol, drug and medication related deaths · Suicide (from 2015) |
| Organisation named | Cornwall Partnership 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 David Morley Sargeant, deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Jackie Pendleton, Chief Officer, NHS Kernow Clinical Commissioning Group 1 CORONER I am Guy Davies, Her Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly. 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 On 22nd June 2017 I commenced an investigation into the death of 48 year old David Morley Sargeant. The investigation concluded at the end of the inquest on 18th October 2018. The conclusion of the inquest was as follows; David Morley Sargeant died on 16th June 2017 at The Ford, Mawgan, Helston, Cornwall, from the toxic effects of an intentional overdose of prescribed and controlled drugs. My conclusion as to the death is that it was Suicide. The medical cause of death was established on the evidence as: 1a) disease or condition directly leading to death - Mixed drug toxicity II) other significant condition(s) which could have contributed to the death but are not related to the disease or condition causing it – suspension by ligature around the neck. 4 CIRCUMSTANCES OF THE DEATH David Sargeant (known to family and friends as Davy) was found deceased in a car in a rural location following an intentional overdose. The doors were locked, the only set of keys were inside the vehicle. Davy had a ligature around his neck which the pathologist considered as secondary measure taken by Davy as part of his intention to kill himself. Davy had a history of drug abuse. Davy had received treatment from the Cornwall drug addiction treatment service, Addaction. Davy displayed a historical pattern 1 of chaotic illicit substance misuse. These periods were usually followed by periods of treatment and stabilisation, which included substitute prescribing and/ or rehabilitation. The Addaction report stated that during these more stable periods in his life he appeared to become more vulnerable to his ‘ADHD and mental health’. 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. – In October 2016 Davy was referred by his GP to the community mental health team (CMHT), part of Cornwall Partnership NHS Foundation Trust (CPT) for assessment of possible ‘Attention deficit hyperactivity disorder’ (ADHD) which is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness. Davy was assessed in December 2016 by CMHT. However, Davy was discharged from CMHT without further diagnosis and treatment. This was because of the following reasons;- 1) CPT is not commissioned to assess, diagnose or treat adult ADHD. Addaction Cornwall does not have access to a specialist psychiatrist with 2) the skills to diagnose or treat ADHD. Although the GP had the option to refer under Patient Choice for 3) treatment out of county, the GPs previous experience indicated that this was impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication. In summary, Davy could not be diagnosed and treated by specialist services either in Cornwall or out of county. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. I recommend that NHS Kernow reviews the arrangements for the diagnosis and treatment of ADHD by specialist services either in Cornwall or out of county, with consideration being given to the following concerns 2 1) CPT is not commissioned to assess, diagnose or treat adult ADHD. Addaction Cornwall does not have access to a specialist psychiatrist with 2) the skills to diagnose or treat ADHD. 3) Although GPs have the option to refer under Patient Choice for treatment out of county, experience indicates that this is impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication. I would be pleased to hear from you in relation to these concerns. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th December 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. – Davy’s mother. I have also sent it to the following who may find it useful or of interest. Phil Confue, Chief Executive, Cornwall Partnership NHS Foundation Trust y, Operations Director, Addaction. Co-coordinator, Drug action team, Cornwall 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 25/10/18 Guy Davies 3
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.
Private and Confidential Mr Guy Davies Her Majesty’s Assistant Coroner for Cornwall & the isles of Scilly Cornwall Coroners’ Service The New Lodge Penmount Newquay Road Truro Cornwall TR4 9AA By Email: cornwallcoroner@cornwall.gov.uk Monday 17th December 2018 Dear Mr Davies, Chief Officer NHS Kernow Clinical Commissioning Group Sedgemoor Centre Priory Road St Austell Cornwall PL25 5AS Tel: c/o 01726 627612 Email: Prevention of future death report following inquest into the death of David Morley Sargeant Thank you for your Regulation 28 Report to Prevent Future Deaths pertaining to Mr David (Davy) Morley Sargeant. In your report you identify a number of concerns and considerations to be taken by NHS Kernow as joint commissioners of mental health and learning disabilities in Cornwall, alongside Cornwall Council. The matters of concern you have raised to be addressed include the review of the arrangements for the diagnosis and treatment of ADHD by specialist services either in Cornwall or out of county. I have noted these concerns and our responses to each below. 1) CFT is not commissioned to assess, diagnose or treat ADHD: NHS Kernow Clinical Commissioning Group (CCG) has not historically commissioned a specialist adult ADHD service. However, in April 2018 it was acknowledged that this constituted a gap in service provision, and therefore an intention was set to develop and operate a pathway for adults (18 years and older) with ADHD. NHS Kernow identified and committed to a recurrent investment for CFT to co-design, develop and deliver the required level of intervention in line with the National Institute for Health and Care Excellence (NICE) guidance. The new service, due to be established in early 2019, will deliver an adult ADHD assessment, diagnosis and treatment pathway. 01726 627800 kccg.contactus@nhs.net www.kernowccg.nhs.uk /nhskernow Chair: Dr Iain Chorlton Chief Officer: Jackie Pendleton Head office: Sedgemoor Centre, Priory Road, St Austell, Cornwall, PL25 5AS A Shared Care Agreement and Guideline for the treatment of ADHD in adults will be developed by the NHS Kernow prescribing team to support the new commissioning model. This will support the prescribing of the evidence based pharmacological treatment, and is supported by an already identified budget within the prescribing team. 2) Addaction Cornwall does not have access to a specialist psychiatrist with skills to diagnose or treat ADHD: Cornwall Council’s Drug and Alcohol Action Team (DAAT) are responsible for the commissioning of Addaction services which provide treatment for adults with substance misuse where ADHD is a co-occurring diagnosis. We would ask that you seek clarification regarding this point from Cornwall Council as the lead commissioner of Addaction. 3) Although GPs have the option to refer under Patient Choice for treatment out of county, experience indicates that this is impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication: GPs are currently able to prescribe in the absence of a specialised pathway but do require specialist knowledge which can impact on whether they feel competent and confident to do so. Once initiated the new adult ADHD pathway will ensure that people in Cornwall will have dedicated assessment, diagnosis and treatment by a specialist service in Cornwall. Our response outlines the arrangements that are being developed for the diagnosis and treatment of adult ADHD by NHS Kernow CCG in Cornwall and the Isles of Scilly. We are committed to monitoring the implementation of these arrangements within the timescales noted. I hope that this response provides you with satisfactory information that we are committed to and are already working closely with partner agencies to take measures to prevent future deaths as set out in the Regulation 28 Report. We are aware that this response may be shared with Mr Sargeant’s family. I do hope that this information will provide them with assurance that actions are being taken in relation to the concerns’ identified in relation to Mr Sargeant’s death. We would like to extend our sincere condolences to the family. Please do not hesitate to contact me if you require anything further in relation to this case. Yours sincerely Chief Officer Page 2
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