Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0405, written 21 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 | 21 Dec 2018 |
|---|---|
| Reference | 2018-0405 |
| Deceased | [REDACTED] |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Midlands Partnership Foundation Trust CORONER I am Mr John Penhale Ellery, Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. 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. INVESTIGATION and INQUEST On 2nd May 2018 I commenced an investigation into the death of 18 years of age, and opened an inquest on the 10th May 2018. The investigation was concluded at the end of the inquest on the 14th and 15th November and 17th December 2018. The conclusion of the inquest was suicide. CIRCUMSTANCES OF THE DEATH . was found deceased . She was found had mental health issues starting from around 15 to 16 years of age. They resulted in self-harm and 2 suicide attempts the last of both which was in September 2017. Mental health care had been provided to before and after her 18th birthday ). She was in contact with mental health services up until the evening of the 30th April 2018 before she killed herself the next morning. CORONER’S CONCERNS On the evidence various issues were addressed and set out in the coroner’s determination and findings and can be referred to for wider reading. Two specific death but issues arose which could not be said to have caused or contributed to could in others. 1 Delay in IAPT counselling a) After turned 18 she moved to adult mental health services. She had parallel contact with her GP surgery . Shortly before 18th birthday, according was referred to Improving to the MPFT clinical review (page 9 of 33), Access to Psychological Therapies (IAPT) by the Access Team for assessment for psychological therapy or counselling. On the 14th November 2017 (page 12 of 33) it was agreed with to add her to her GP surgery waiting list for counselling in line with her treatment preference. remained on the IAPT waiting list for counselling at the time of her death. b) The evidence at the inquest was that a 3 month time interval would be optimal case, in relation to this GP surgery, 10 months would be the but in norm. Such a delay is sub-optimal and could have an adverse effect on a 1 6 7 8 patient waiting for counselling to commence. 2. Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written. b) This is distinct from progress notes and/or risk assessments being accurately recorded. It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes. Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 15th 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to • • • • • Lanyon Bowdler solicitors for , father of , brother of , legal representative of the MPFT , mother of . , 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. 2 9 Mr John Penhale Ellery Senior Coroner Shropshire, Telford & Wrekin 21st December 2018 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.
r4!1:ki Midlands Partnership NHS foundation Trust A Keele University Teaching Trust · Trust Headquarters .. St George's Hospital · Corporation Street Stafford ST163SR 2nd February 2019 · J.P. Ellery Senior Coroner HM Coroner's Services Shirehall Abbey Foregate Shrewsbury Shropshire; SY2 6ND Dear Mr Ellery RE: Report to Prevent Future Deaths Thank you for your letter dated 21st Decembe� 2018, reporting a matter to us, in acco�dance with Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. · May I take this opportunity to reassure you that following undertook a thorough investigation into the care delivered by the Trust. death, we Following discussions within the teams involved, I ani now in a position to respond to your specific concerns, where by you. stated you heard at the inquest during the course of the evidence: 1. Delay in IAPT Counselling turned 18 she moved to Adult Mental Health Services. She had After parallel contact with her GP surgery in Shortly before 18th birthday according to the MPFT Clinical Review (page 9 of 33), Therapies (IAPT) . was referred to Improving Access to Psychological I by'the On 14th November 2017 (page 12 of 33) it was agreed with her GP surgery waiting list for counselling in line with her treatment'preference. Access Team for assessment for psychological therapy or counselling. to add her to remained on the IAPT waiting list for counselling at the time of her death .. The evidence at the inquest was that a 3 month time interval would be optimal but in fi'1:b1. Midlands Partnership NHS foundation Trust t A Keele Universi y Teaching Trust case, in relation to this GP surgery, 10 months would be the norm. Such a delay is sub-optimal and could have an adverse effect on a patient waiting for counselling to commence. Historically, counselling provision i model and commissioned from a number of providers, including /APT. Since January 2019 the commissioning arrangements for GP counselling i changed, so that /APT will inefuture provide allecounselling provision across the county. The existing provision is person centred ineorientation where the patient will be given information and then decide where they would prefer to be seen. has been provided from a practice•based haveebeen Theerevised model eligibility criteria will give the /APT service increased capacity, enabling greater flexibility with regard to where and when people can be seen. A 3- month transitionaleperiod is currently underway during which a redesign ofthe /APT service is tak(ng place, whereby counselling provision will be more consistently provided across theecounty from a locality based mode./J which is mo_re efficient and therefore it will be more· possible to be flexible. in responding to changes in supply of staff to meet changes in demand thus reducing waiting times to within the statutory 18 week target. It is anticipated thateonce this work is completed, planned within a six month timescale, it will then beepossible to keep waiting times within theseerecommended limits. 2. The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have bee,n overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written. The Trust uses the Rio system for electronic patient records. It is impossible for clinicale staff to overwrite fields Jn Rio forms to change or delete an entry once it has been madee without the system recording this. Records of all changes can be viewed by the cliniciane through clicking on the "history" tab ..When a Subject Access Request is made, oure Health Records department print out the most up to date record. The "how to guides fore the forms in Rio are currently being updated to instruct staff how to find the history ofe an entry. Where the previous versions are requested, these are printed out as secondarye notes which include the dates the changes were made unfortunately, at present the onlye way to identify what the exact change was, 'is to compare the 2 sets of notes. We aree currently looking at further developing the system to address this issue.e In regard to the validation of notes, legally it is only students who must have theire records validated by a qualified member of staff. All other staff are required to validatee their own entries. The action of validating the entry represents the electronic signaturee of the accuracy and confirmation of that entry. The Trust has explored with our healthe information colleagues whether the default could be an automatic validation which ise then "unticked" but this is not achievable given that some staff must have their entriese •• •�••MPFT
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