Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0370, written 21 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Nov 2018 |
|---|---|
| Reference | 2018-0370 |
| Deceased | Ursula Keogh |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire (West) |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
IN THE WEST YORKSHIRE WESTERN CORONER’S COURT IN THE MATTER OF: The Inquests Touching the Death of Ursula Niamh MacEochaigh Keogh _A Regulation Report — Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: Minister for Department Health . NHS Calderdale Clinical Commissioning Group Chief Executive Calderdale Council CORONER Martin Fleming HM Senior Coroner for West Yorkshire Western CORONER’S LEGAL POWERS . I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 20 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On 30/1/18 I opened an inquest into the death of Ursula Niamh MacEochaigh Keogh who, at the date of her death was aged 11 years old. The inquest was resumed and concluded on 15/11/18 I found that the cause of death to be: - la. Head injury Ib Fall from a height l arrived at a narrative conclusion as follows: On 22/1/18 Ursula Niamh MacEochaigh Keogh intended to take her own life. CIRCUMSTANCES OF THE DEATH On 22/1/18 Ursula left her school at Lightcliffe Academy and boarded the school bus in company with her friend. At approximately 3.30pm Ursula got off a stop earlier than usual and made her way to the North Bridge in Halifax from which she jumped. She was subsequently located at 6.20am in the river approximately 100 yards away from the Shears Inn Public House, 2km downstream from the North Bridge. When Ursula was retrieved from the waters paramedics found that she had very sadly RT3589 i] | passed away and this was confirmed at the hospital. 5 | CORONER'S CONCERNS During the inquest I heard that Ursula’s mother contacted Ursula’s GP at spring Hall Medical Centre by telephone on 13/11/17 in order to discuss her concerns about Ursula’s history of self-harm and that this resulted in her mother being advised by a GP to get Ursula’s school involved. Although the school subsequently advised Ursula’s mother to contact her GP, during the telephone conversation of 14/12/17 to further discuss Ursula’s self-harming, the GP advised her mother to contact the Psychology Team attached to the school, so that Ursula could be assessed for referral to Child & Adolescent Mental Health Team if necessary, in accord with the protocol previously issued by Calderdale CAMHS referral pathway, notwithstanding that at this time the school did not have the services of a Psychology team to make the referral. I further heard helpful evidence from TE 2:25 Asset Manager, Calderdale Council), who told me about the current plans for preventative measures at North Bridge, Halifax in order to deter further like tragedies. The MATTER OF CONCERN is as follows: - e To review the current practice of referral by GP to the school for consideration as to the appropriateness of referral to CAHMS e Consider improving communications between professionals, particularly health and education to eliminate contradictions offered in the advice. e Consider the appropriateness of fast tracking the implementation of preventative measures currently under consideration at North Bridge Halifax 6. | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Minister for Department of Health, NHS Calderdale Clinical Commission Group and Chief Executive for Calderdale Council have the power to take such action specific to them. In the circumstances it is my statutory duty to report to you. RT3589 2 <a YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be. taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. COPIES Ihave sent a copy of this report to: BE sn — Head of Behaviour, Attendance and Safeguarding Abbey Multi Academy Trust -GP Principal of Lightcliffe Academy Chair of CSCB He Chair of Serious Case Review and Learning Lesson review panels — Calderdale Clinical Commissioning Group HS - Public Health Consultant and Chair of child Death Overview Panel Eh oterim Business Manager of CSBC e Chief Coroner DATED this 21/11/18 _ Senior Coroner — West Yorkshire - Western Division Md Fier, RT3589 3
2 responses 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.
Calderdale Clinicat Commissioning Grour rt 16 JAN 2019 M.D Fleming 4 a menggit Senior Coroner eae. TR City Courts The Tyrls Bradford BD1 1LA Date: 15/1/2019 IN CONFIDENCE Dear Mr Fleming, Re: Regulation Report on the Inquest Touching the Death of Ursula Niamh MacEochaigh Keogh - Action to Prevent Future Deaths Thank you for sending a copy of the above report, received on the 28" November 2018. We have carefully considered the three matters of concern raised with us and worked in partnership with Calderdale Council to agree a set of actions which we have attached as required. Our response has been compiled in partnership with Calder iy’ i id Young People’s senior managers and the CCG’s clinical lead, is also a GP member of our Governing Body. A meeting was convened to produce the attached action plan which we trust will provide you with the necessary assurance that existing processes have been reviewed and revised with new actions identified to prevent future deaths occurring. Provided below is a brief response to the three recommendations raised in your report. Please also see the attached action plan which sets out the existing and new actions identified. 1. To review the current practice of referral by GP to the school for consideration as to the appropriateness of referral to CAMHS. The group reviewed the existing Child and Adolescent Mental Health Service (CAMHS) referral pathway-for GPs and schools (copy enclosed). Following a comprehensive discussion, the group were satisfied with the accuracy of the process described. However, the review highlighted some gaps in respect of external training and education about the pathway which has resulted in the new actions set out in the attached. 2. Consider improving communications between professionals, particularly health and education to eliminate contradictions offered in the advice. Chair | Dr Steven Cleasby ys Chief Officer | Dr Matt Walsh JS — 5th Floor, F Mill, Dean Clough, Halifax, HX3 5AX oe agg Ci the peas T. 01422 307400 | E: ccgfeedback@calderdaleccg.nhs.uk | www.calderdalecca.nhs.uk INHS ; Calderdale Clinical Commissioning Grou The group noted the widespread training and education programmes being delivered by services to key partners, parents and carers in Calderdale. However, it also recognised the importance of ongoing training, education and communication plans. The multi-agency Open Mind Partnership (CAMHS) Steering Group will take ownership of the attached action plan. The Steering Group will monitor delivery against this plan at its monthly meeting, reporting into the CCG’s Quality Committee. 3. Consider the appropriateness of fast tracking the implementation of preventative measures currently under consideration at North Bridge Halifax A discussion has been held with Calderdale Council's Public Health Consultant (Lead for Mental Health) and a full response will be provided by Calderdale Council on this recommendation. Below is a summary of the response: 4 ° A review was undertaken of North Bridge in January 2018 looking to prevent further suicides at this location. e This outlined the need for installation of anti-climb mesh affixed to horizontal rails. ° A resolution was passed by the Council for an application for listed building consent and an application for planning permission is submitted to the Local Planning Authority. ° The listed building application has been approved and consent has now been granted with the works to be completed by the end of May 2019. The Council has also installed an additional CCTV camera to provide coverage of North Bridge. We hope that the above, together with the enclosed action plan, demonstrates the seriousness with which we have viewed this case and ask that our sincere condolences be passed onto the family. Yours sincerely, a Dr Matt Walsh Chief Officer Enc. Chair | Dr Steven Cleasby Chief Officer | Dr Matt Walsh 5th Floor, F Mill, Dean Clough, Halifax, HX3 SAX T. 01422 307400 | E: ccafeedback@calderdalecca.nhs.uk | wan calderdatecca nhs. it
/. asi-18 ae D tm t Parliamentary Under Sens Ge eee ie ne inequalities and Suicide Prevention of Healt! Social Care aim ares SW1H OEU Your Ref: MDF-HK/251-2018 a Pac Our Ref: PFD-1158450 Mr Martin Fleming HM Senior Coroner, West Yorkshire (Western) HM Coroners’ Office , City Courts The Tyrls | Bradford BD1 1LA March 2019 Dra M- PRM, Thank you for your correspondence of 26 November 2018 to the Department of Health and Social Care about the death of Ursula Niamh MacEochaigh Keogh. I am replying as the Minister with responsibility for child and adolescent mental health services (CAMHS), and I am grateful for the extra time in which to do so. Your report raises three matters of concern and is directed to NHS Calderdale Clinical Commissioning Group (CCG) and Calderdale Council, as well as the Department of Health and Social Care. I am aware that the Calderdale CCG has responded to your concems from a local perspective, advising you of a series of actions that are being undertaken in light of the report. We expect the local NHS to take action to respond to concerns.and learn from deaths to ensure the safety of healthcare services and I am encouraged that the local NHS is looking into these matters carefully. It may be helpful if I set out work undertaken nationally to help local services work together to deliver improved outcomes for children and young people experiencing mental health difficulties. Future in Mind’, published by the Department and NHS England in 2015, set out a consensus across the NHS, public health, local authorities, social care, schools and youth justice sectors to work together to promote good mental health, prevention and early intervention; improve access; and deliver a clear, joined-up approach. This led oe etpeaomnnay to the development of Local Transformation Plans that set out how local services would work together to deliver improved outcomes. The Five Year Forward View for Mental Health’, published in February 2016, reconfirmed the vision set out in Future in Mind. In Novernber 2018, the Department for Education produced an update to its guidance, Mental health and behaviour in schools’, that includes risk and protective factors for children and young people, including identifying children with possible mental health problems. Guidance is also given on making referrals to CAMHS quickly and efficiently, and allowing pupils to access CAMHS at school. All health professionals, including GPs, are required to take account of guidance issued by the National Institute for Health and Care Excellence (NICE). The NICE Quality Standard for Self-Harm, QS34* was published in 2013 and includes guidance that people, including those aged eight to 18, who have self-harmed, should have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and risks of repetition or suicide; and that people receiving continuing support for self-harm have a collaboratively developed risk management plan. Turning to your recommendations specifically, the Department agrees that communication between health and education professionals needs to be improved. Transforming Children and Young People’s Mental Health Provision: a Green Paper’, jointly published with the Department for Education in December 2017, brings together health and education to provide early intervention mental health support for children and improve communication between health and education professionals. On 20 December 2018, the Government announced the first wave of 25 trailblazer sites that will test the plans set out in the Green Paper. These new plans will significantly increase the availability of mental health support to children and young people, including creating new Mental Health Support Teams working in and near schools and colleges to support children and young people with mild to moderate mental health conditions. Mental Health Support Teams will provide brand new ? https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-F YF V-final.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/755135/Mental_healt h_and behaviour _in schools pdf 4 https://www.nice.org.uk/; ‘guidance/qs34/resources 5 https://www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a- green-paper services situated in schools and colleges and are intended to offer earlier help and intervention. For example, linking up with existing mental health services which may include local troubled families’ coordinators; educational psychologists; school nurses; health visitors; local children’s services; school counsellors; and voluntary and community sector provision. The Department agrees with your recommendation highlighting the importance of preventative measures and I welcome the measures being taken by Calderdale Council to install preventative measures at the North Bridge Halifax by the end of. May 2019. One of the key areas for action in the cross-government Suicide Prevention Strategy is to reduce access to the means of suicide which is known to be one of the most effective methods of preventing suicide, and this includes those places that we know about across the country that are frequently used for suicide. You may also wish to note that the Government published the first cross-Government Suicide Prevention Workplan in January 2019 which set out an ambitious programme to reduce suicides, including in children and young people®. Furthermore, setting up 24/7 crisis care provision for children, young people and their families is a key priority for the Government in the NHS Long Term Plan’, published on 7 January 2019. All children and young people experiencing crisis will be able to access crisis care 24 hours a day, seven days a week by 2023/24 via NHS111. Finally, although you do not raise this issue in your report, I am aware that Ursula’s family have expressed concern about the role of harmful suicide and self-harm content on social media in relation to Ursula’s death. The Department is very concerned about the impact of this sort of content and is working with the Department for Digital, Culture, Media and Sport (DCMS) and the online sector to address this. Our ambition is to make the UK the safest place to be online and we are working with internet and social media providers to tackle online harms such as these. You may be aware that the Secretary of State for Health and Social Care, Matt Hancock, wrote to social media providers in January to express his concern about suicide and self-harm content on their platforms. I also met social media providers in February, alongside the Secretary of State, and they have committed to step-up their efforts to protect their users from harmful suicidal and self-harm content online. We are also taking action through the forthcoming joint DCMS and Home Office Online G hitps://www.gov.uk/government/publications/suicide-prevention-cross-government-plan 7 https://www.longtermplan,nhs.uk/ Harms White Paper, which will set out a range of legislative and non-legislative measures detailing how the Government will tackle online harms. I hope this information is heipful. Thank you for bringing these concerns to my attention. JACKIE DOYLE-PRICE
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