Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0334, written 27 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Sep 2018 |
|---|---|
| Reference | 2018-0334 |
| Deceased | Sheila Hadfield |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health 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 /2 | CORONER'S LEGAL POWERS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health | CORONER lam Alison Mutch ,Senior Coroner, for the coroner area of South Manchester | 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 T INVESTIGATION and INQUEST On 2°? October 2017, | commenced an investigation into the death of Sheila Ann Hadfield. The investigation concluded on the 17" September 2018 and the conclusion was one of Narrative: Died from the recognised complications of a natural cause exacerbated by a period of immobility following an accidental fall. The medical cause of death was 1a Sepsis; 1 b Left sided empyema and purulent pericarditis;1 c Left sided bronchopneumonia 1 Sheila Ann Hadfield had a long standing mental health disorder of paranoid schizophrenia. She resided at Chester House, a residential care home. As part of her illness she self-neglected including poor personal hygiene and refusal of food. She would regularly stay in her room for significant periods of time and refuse access to care home staff. On 17th August 2017 it was identified that a best interest meeting would be beneficial as the home was struggling to cope. There were limited opportunities for placement elsewhere. She went to her room on 21st September 2017. She did not come out for meals on 22nd September and refused access to her room. At about 14.00 on 22nd September 2017 she was found on the floor of her room by care staff. An ambulance was called and she was transferred to Stepping Hill Hospital. She was treated for sepsis. On 19th September | 2017 she died at Stepping Hill Hospital from sepsis. | 1 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. The inquest heard that the home that Mrs Hadfield was placed in struggled to cope with her needs. However, there was a national shortage of suitable beds for individuals of a similar age to Sheila Hadfield with her complex mental health needs. The majority of available care provision was dementia beds which would have been unsuitable. The inquest was told that this meant that had Mrs. Hadfield not remained where she was she would have had to go onto a mental health ward on a voluntary basis or been sectioned if she had refused. T 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 22"4 November 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 I | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Mrs Evans, sister of Sheila Hadfield and daughter of Shelia Hadfield , who may find it useful or of | interest. | 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. Allison Mutch OBE HM Senior Coroner 27.09.29018 ov
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.
uy From Jackie Doyle-Price MP’ Department Pesta Unies Sacra ol Sie i Neal et oT riea Social Care 39 Vlora Stet SWIH OEU Your Ref: 8339/CLB 020 7210 4850 PFD-1151095 Ms Alison Patricia Mutch HM Coroner's Court 1 Mount Tabor Street Stockport SKI 3AG ‘ (\ November 2018 DRay VA Mukes Thank you for your correspondence of 27 September to Matt Hancock about the death of Mrs Sheila Ann Hadfield. I am responding as Minister with portfolio responsibility for mental health. My officials have made enquiries with NHS England on the matter of concern in your report. From the information provided, it appears that the main issue is about the availability of appropriately trained and resourced social care services, including care homes with specialist mental health staff and seamless interfaces with secondary mental health services specialising in older people’s functional mental health. NHS England acknowledge that access to mental health expertise within care homes, whether through referrals, staff training or integrated teams, is not always adequate. Older people in care homes typically have more complex health and social care needs than those living in their own homes, yet access to healthcare, and mental health care in particular, for this group of service users is not always adequate. There is evidence that care home residents can experience problems accessing NHS primary and secondary healthcare services, including GPs. It is important that care homes ensure they have good links with GPs and referral arrangements in place so that healthcare services can be accessed easily and promptly as and when needed. Quality Standard QS50, Mental wellbeing of older people in care homes' published by the National Institute for Health and Care Excetlence (NICE), recommends that ‘older people in care homes have access to the full range of healthcare services when they need them’, and that care homes ensure they ‘... work in partnership with healthcare organisations to implement effective arrangements for access to primary, secondary, specialist and mental health services for older people in care homes’. Ata national level, NHS England has taken steps to help improve healthcare in care homes through the roll out of ‘Enhanced Health in Care Home’ Vanguards? as part of the Five Year Forward View’s New Models of Care Programme. Many of the Vanguard sites have included some mental health components in their care models, with several reporting positive results and learnings that other areas could benefit from. For example, in sites that have incorporated mental health expertise into integrated care teams such as the Gateshead Vanguard, team members have highly valued the contribution of their mental health colleagues in improving the support delivered to people with complex and ongoing care needs. This has included support for older people with functional mental health needs such as depression, anxiety, bipolar disorder and schizophrenia. Building on the experience of the Vanguard sites, the development of Integrated Care Systems (ICSs) and Sustainability and Transformation Partnerships (STPs) provides a valuable opportunity to strengthen collaboration between health and social care services in a local footprint, and to help improve the provision of mental health care in care homes. Such arrangements are for local areas to determine, according to the local need and the make-up of local services. I hope this response is helpful. Thank you for bringing these concerns to my attention. i pe JACKIE DOYLE-PRICE
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