Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0045, written 11 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2019 |
|---|---|
| Reference | 2019-0045 |
| Deceased | Paul Gillam |
| Coroner | Guy Davies |
| Coroner area | Cornwall & the Isles of Scilly |
| Category | Alcohol, drug and medication related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| 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.
IN THE TRURO CORONERS COURT IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF PAUL MATTHEW GILLAM REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) , Head of Mental Health and Learning Disability commissioning NHS Kernow (2) Philip Confue Chief Executive Cornwall Partnership NHS Foundation Trust (3) Joint Commissioning Manager Cornwall & Isles of Scilly Drug and Alcohol Action Team Cornwall Council 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 14th June 2018 Cornwall Coroners commenced an investigation into the death of 47 year old Paul Matthew GILLAM. The investigation concluded at the end of the inquest on 8th February 2019. The four questions - who, when, where and how – were answered as follows … Paul Matthew GILLAM died on 3rd June 2018 at flat 8, 34 Downs View, BUDE, from the toxic effect of a reckless overdose of non-prescription and prescription drugs. My conclusion as to the death is that it was a Drug Related Death. 1 The medical cause of death was established on the evidence as 1a (namely the condition directly leading to death) - Synergistic toxic effects of several central nervous system depressants. The pathologist noted that the toxicology ‘… results show the presence of morphine and methadone at potentially toxic levels… Diazepam, gabapentin and sertraline were detected at therapeutic levels. CNS depressant drugs may act synergistically to enhance their toxic effects on the cardiorespiratory system…’ 4 CIRCUMSTANCES OF THE DEATH Paul was found dead in his bed at his home address on 5th June 2018 by friends. Paul had a previous medical history of asthma, emphysema, depression, anxiety, chronic obstructive pulmonary disease (COPD), drug and alcohol abuse, including a history of heroin abuse. was the last person to see Paul alive, on 3rd June 2018. Paul had spent the afternoon drinking in the gardens at Paul’s home address. Paul had arrived at 1400 hours – already under the influence of drugs or drink, and was seen to consume vodka and take six pills, of unknown composition. At around 1930 hours difficulties walking; helped Paul back to his room, at this time Paul was having d assumed this was due to Paul’s COPD. Paul was not seen alive again after the party on Sunday 3rd June and was found deceased wearing the same clothing on Sunday, when he was last seen. There was no evidence of any intent to end his own life or of any third party involvement. Due to Paul's lifestyle and his poor health, a combination of an overdose of drugs and his already weakened respiratory system, likely lead to him dying whilst asleep on 3rd June 2018. Paul had been under the care of Addaction, drug and alcohol treatment team since his arrival in Cornwall in 2012. There had been a number of referrals to the community mental health team (CMHT). The evidence indicated that the concerns for Paul’s mental health were ongoing throughout treatment. Paul continued to experience episodes of paranoia, low mood and anxiety until his death. The evidence revealed issues in communication between Addaction and CMHT. It was unclear to Addaction why Paul's initial support was ended or why Addaction did not receive further feedback from the further referral in July 2017, other than 2 being advised in August 2017 that Paul was awaiting allocation of a CPN. Addaction were not aware of the repeated failures by Paul to attend appointments with CMHT or the recommendations made by CMHT for Paul to engage in voluntary work. Addaction gave evidence that if they had known of the non-attendance record that steps would have been taken to ensure Paul’s attendance. Addaction were aware that non-attendance at CMHT may lead to discharge. The evidence suggested that Addaction were unaware of the full extent of the work undertaken by CMHT or of Paul’s subsequent lack of engagement with CMHT. The court heard that the appropriate policies and service level agreement (SLA) had been developed but that the issue lay with communication between Addaction and CMHT, and the implementation of the policies and the delivery plan concerning the relationship between Addaction and CMHT. The court heard the working relationship between Addaction and CMHT could be improved. The court did not seek to resolve the issues between CMHT and Addaction. The reasons for the communication breakdown were not directly relevant to the statutory questions that had to be answered by the court. Nevertheless, the issue of the communication breakdown is relevant to the concern of the court to prevent future deaths. There was no requirement to pursue an enquiry in order to seek to unravel the reasons for the breakdown and attribute blame. That is not the role of the Coroners Court, and in addition such an enquiry was not necessary to fulfil the obligations of the Coroners Court. 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 - (1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT. (2) The development and implementation of the delivery plan in relation to the existing service level agreement between CMHT and Addaction. (3) The working relationship between CMHT and Addaction. 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. 3 (1) To review the operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT. (2) To review the development and implementation of the delivery plan concerning the relationship between CMHT and Addaction. (3) To consider how best to encourage a closer working relationship between CMHT and Addaction. 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 8th April 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; (father) I have also sent it to the following who may find it useful or of interest; , Addaction Team Leader , Drug Related Death Prevention Coordinator 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 [DATE] [HM CORONER] 11th February 2019 Guy Davies 4
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.
Chief Officer NHS Kernow Clinical Commissioning Group Sedgemoor Centre Priory Road St Austell Cornwall PL25 5AS Philip Confue Chief Executive Cornwall Partnership NHS Foundation Trust, Carew House Beacon Technology Park Dunmere Road Bodmin PL31 2QN Joint Commissioning Manager Helford House May Court Truro Business Park Threemilestone TR4 9LD Private and Confidential Mr Guy Davies Cornwall Coroners Service The New Lodge Penmount Newquay Road Truro Cornwall TR4 9AA By Email: cornwallcoroner@cornwall.gov.uk 28 March 2019 Dear Mr Davies Prevention of Future Death Report following inquest into the death of Paul Matthew Gillam Thank you for your Regulation 28 Report to Prevent Future Deaths pertaining to Paul Matthew Gillam. NHS Kernow Clinical Commissioning Group (CCG), Cornwall Partnership NHS Foundation Trust (CFT) and Cornwall Council (CC) have agreed to complete a single response to the Regulation 28 Report in order to demonstrate commitment to the actions that are being taken to address the identified concerns. In the Regulation 28 Report you have identified the following actions to be taken in relation to the matters of concern: 1) To review the operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT 01726 627800 kccg.contactus@nhs.net www.kernowccg.nhs.uk /nhskernow Chair: Chief Officer: Head office: Sedgemoor Centre, Priory Road, St Austell, Cornwall, PL25 5AS 2) To review the development and implementation of the delivery plan concerning the relationship between CMHT and Addaction. 3) To consider how best to encourage a closer working relationship between CMHT and Addaction In order to provide our response we would like to confirm the commissioning arrangements linked to the actions: NHS Kernow CCG commissions the services of CFT who operates the community mental health teams (CMHT). CC commissions the services of Addaction. These commissioning arrangements are defined in contracts which stipulate a requirement to undertake joint working where necessary. However, as you have noted, there have been issues with the interface between the CMHT’s and Addaction services signalling concerns in relation to joint working. In order to support this multi-agency joint working there is a Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults covering the period 2016 - 2019. This is a multi-agency co- produced strategy that has been developed by members of Safer Cornwall and providers of services. The purpose of this strategy is to assist with the delivery and experience of integrated and inclusive service delivery for people with co-existing mental health and substance misuse problems, and their associated complex needs. However, as acknowledged in the strategy, there are challenges to creating a culture of shared responsibility which can leave people struggling to gain access to evidence based interventions as well as targeted support for substance misuse. A multi-agency steering group has been set up to review the strategy and develop an implementation plan. The steering group consists of key organisations (including CFT and Addaction) and is being supported by the commissioning organisations. The steering group will report progress into the Mental Health Crisis Care Concordat who will report to Safer Cornwall. The Crisis Care Concordat is a national agreement between services and agencies involved in the care and support of people in crisis and sets out how organisations will work together. These arrangements will ensure the review of the strategy and its implementation, as well as appropriate oversight of progress and effectiveness. Key to the strategy is the safe and timely sharing of information and communication between organisations that specifically include CFT and Addaction, as well as other organisations involved in supporting individuals with co-existing needs. Progress to date includes an exceptional Crisis Care Concordat meeting which was held on the 22nd January 2019 and which was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions were identified to complete the strategy review and develop/implement a robust multi-agency implementation plan. There have since been two multi-agency steering group meetings with the third meeting taking place on 1 April 2019. It is expected that the review of the strategy and comprehensive development of the implementation plan will be completed by the end of July 2019. The process will involve the reviewing of current active cases to ensure learning and improvements are being made for people whilst this work is being undertaken. Page 2 In order to further strengthen monitoring arrangements both commissioning organisations are reviewing contractual expectations to ensure engagement with the review, development and implementation of the dual diagnosis strategy. I hope that this response provides you with reasonable information that we are committed to and are already working closely with all partner agencies to take measures to prevent future deaths as set out in the Regulation 28 Report. We have sent a letter to the Coroner’s officer to share with the family to invite them to be involved should they wish to do so. Mr Gillam’s father has confirmed that he does not wish to be involved at this time. We would like to repeat our offer to make contact should he want to do so in the future. We are aware that this response will be shared with him and I do hope that this information will provide him with assurance that actions are being taken in relation to the concerns’ identified in relation to his son’s death. We would like to extend our sincere condolences to him and the family. Yours sincerely, Chief Officer NHS Kernow Philip Confue Chief Executive Cornwall Partnership NHS Foundation Trust Joint Commissioning Manager Cornwall and Isles of Scilly Drug and Alcohol Action Team Cornwall Council Page 3
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