Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0385, written 12 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Dec 2018 |
|---|---|
| Reference | 2018-0385 |
| Deceased | Neil Swaisland |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Suicide (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | West London NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO : Michael Bracey, Chief Executive Milton Keynes Council And 1 CORONER , Chief Operating Officer Milton Keynes Central Commissioning Group I am Thomas R Osborne, Senior Coroner for Milton Keynes 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 16/07/2018 I commenced an investigation into the death of Neil Stephen David SWAISLAND aged 49. The investigation concluded at the end of the inquest on 28th November 2018. The conclusion of the inquest was: Suicide 4 CIRCUMSTANCES OF THE DEATH The deceased went to the top floor of the multi storey car park situated in Cresswell Lane, Milton Keynes at 12.50 on 14th July 2018 and jumped to the ground below sustaining multiple injuries. He was confirmed dead at the scene at 13.51 the same day. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows : During the course of the evidence I heard from a senior GP from Milton Keynes and from a senior clinician from mental health services that the funding for counselling services operated by MIND had been withdrawn by both the Council and the CCG. They expressed the view that as a result of this decision it is inevitable that further lives will be put at risk from self-harm and suicide. My concern is that the decision not to provide counselling to some of the very vulnerable people within our society will result in further deaths from suicide. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action by reviewing the provision of counselling services in Milton Keynes. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5th February 2019. 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 Milton Keynes University Hospital, Central and North West London NHS Trust The Family of Mr Swaisland I have also sent a copy to MIND, The GP Practice and Compass who may find it useful or of interest. 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 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 12 December 2018
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.
NHS) Milton Keynes 10 January 2019 Clinical Commissioning Group HM Coroner's Office Civic Offices een . mages NHS Milton Keynes Clinical Commissioning Group 1Saxongateeast | Sherwood Place 155 Sherwood Drive wees paynes | 14 JAN 219 Bletchley MK3 6RT 7 Telephone: 01908 278685 Email: Dear Mr Osbourne Web: www.miltonkeynesccg.nhs.uk Re Regulation 28 Report | am writing in response to your regulation 28 report dated the 12 December, following the death of Mr Swaisland, who died on 14 July 2018. Thank you for inviting comment from Milton Keynes CCG (MKCCG) in this case. Your report requests specific information in relation to access to counselling services within the borough and the specific feedback from clinicians reporting to the inquest in relation to MIND counselling services. Milton Keynes Council (MKC) has a historic contract for counselling services in Milton Keynes. MKCCG contributed towards the cost of this provision. MKC have been working with MIND for a number of years to ensure that this contract can operate with resource from grant funding and other opportunities available to third sector partners. The contract was due to end in 2017/18, however, statutory grant funding from both MKC and MKCCG has been maintained in 2018/19 to ensure continuation of the contract until March 2019. From April 2079, MIND will work with community funding options. The intention is for access to subsidised counselling to be maintained. The CCG has invested year on year into Improving Access to Psychological Therapies (IAPT) service provision. | am pleased to say that following additional investment the local provider, Central and North West London (CNWL), is exceeding all access, and waiting time requirements against the national specification. The service is provided from 3 locations in Milton Keynes and over 400 people are currently entering treatment each month. We anticipate that over 4500 people will have received treatment in 2018/19. In addition the service has maintained an excellent recovery rate, in excess of the national target set. In addition the CCG has invested in a Primary Care Plus (PCP) service working with general practice to provide access to specialist support for people with serious mental illness and increasing mild and moderate need in primary care. This service will be developed to meet the needs of ail of the registered population in 2019. | hope that this provides you with the appropriate information relating to this case and assurance about the focus for the development of Mental Health commissioning plans and provision for Milton Keynes Yours sincerely Chief Operating Officer
Reply to 7
Call 01908252200 Ref MB/LW milton
E-mail
Private & Confidential
Mr Tom Osborne
HM’s Senior Coroner for Milton Keynes
Via email: coroners.office@milton-keynes.gov.uk
4 February 2019
Dear Mr Osborne
Regulation 28 report to prevent further deaths
I'm writing in response to your regulation 28 report of 12 December 2018, regarding the death of
Mr Neil Swalsiand on 14 July 2018. You have requested information in relation to access to
counselling services within Milton Keynes.
Milton Keynes Council (MKC) has a contract for counselling services in place with MIND, Milton
Keynes Clinical Commissioning Group (MKCCG) also contributes towards the cost of this provision.
This contract was due to end in December 2018 however a continuation of funding from MKC and
MKCGG will maintain it until April 2019 whilst MIND develop additional funding opportunities for
their services. After April the council will no longer directly commission counselling services,
instead focusing our investment Into our frontline mental health social care services,
The NHS is continuing to provide counselling services in Milton Keynes. MKCCG have continued
their commitment to the provision of psychological therapies in Milton Keynes through the
Improving Access to Psychological Therapies {IAPT) service provision. The local NHS mental health
service provider, Central and North West London Foundation Trust (CNWL), Is currently meeting
all national access, and walting time requirements for these services. MIND is working with the
IAPT service delivering the triage service.
In addition, working in partnership with MKC and CNWL, MKCCG have invested in a Primary Care
Plus service working with general practice to provide access to specialist support for people with
mental illness in primary care. This service will be developed to meet the needs of all of the
registered population in 2018.
Yours sincerely
Michael Bracey
Chief Executive
Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3E)
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