Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0046, written 12 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 | 12 Feb 2019 |
|---|---|
| Reference | 2019-0046 |
| Deceased | Heather Carey |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Rt Honourable J Doyle-Price, Minister for Suicide Prevention, Department for Health and Social Care, 39 Victoria Street, London SW1H OEU 2 chair NHS Tameside and Glossop Clinical Commissioning Group (CCG), Dukinfield Town Hall, King Street, Dukinfield SK16 4LA CORONER Andrew Bridgman Assistant Coroner, for the coroner area of South Manchester CORONER'S LEGAL POWERS | 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 Inquest touching the death of Heather Louise Carey. Opened 8" January 2018 Concluded 1 November 2018. Medical Cause of Death 1a Hanging Conclusion Suicide. Heather Carey took her own life when she had been in the care of NHS Mental Health Services for 6’ months; she had recently been placed on a waiting list of some 24 weeks for Cognitive Analytical Therapy. Although Heather Carey was known to be depressed, compounded by the lack of medication prescribed to lessen that depression, and at high risk of suicide from the time she had been discharged from hospital (following a serious overdose 6 weeks prior to her death) there was a failure to take adequate and appropriate action to avert or reduce that risk and, just 2 days before her death, inappropriate steps were taken which may have increased that risk. CIRCUMSTANCES OF THE DEATH On 04.07.17 Heather Carey was admitted as a voluntary patient to the Mental Health Unit, Tameside General Hospital, seeking treatment for her enduring mental illness diagnosed as bi-polar disorder. Heather was detained under section 2 of the Mental Health Act on 13.07.17. On 24.08.17 Heather Carey was discharged. Her discharge medication was quetiapine, intended to lessen the depth of her depressive mood swings. Heather was expecting a referral to have been made that day for a psychotherapy assessment. On discharge Heather Carey's Out Patient Clinic Appointment was to be within 2-3 weeks (14.09.2017) but she was given an appointment on 04.10.17. Following this appointment Heather was referred for psychotherapy screening/assessment. That is the usual practice. On 02.11.17 Heather was admitted to Tameside General Hospital having taken an overdose of paracetamol. Quetiapine was stopped pending liver and renal function tests. Heather was discharged from Tameside General Hospital on 10.11.17. From discharge Heather Carey was a Red Zone high priority patient. Heather attended for her psychotherapy assessment on 22.11.17. The psychotherapist was not aware of the recent overdose. Heather was told that she was ready to consider Cognitive Analytical Therapy but that there was a 24-week waiting list. The psychotherapist sensed a disappointment. The evidence showed that for Heather it seemed like all hope had gone. Thereafter Heather's disengagement from the mental health team worsened. On the morning of 20.12.17 Heather Carey hanged herself at her home. CORONER'S CONCERNS The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin. At the time of Heather's admission to TGH there was no psychotherapy available to her as an in-patient because there were insufficient funds available to provide the same. | was told that had been addressed by further funding being made available. At the time of Heather's assessment on 22.11 staffing levels were reduced, through iliness and a vacancy, and there was only one psychotherapist available. That was the reason given for the 24 weeks wait. At the inquest | heard evidence that the target waiting list was 18 weeks. Further, that by the time of the inquest that target time was being met. A target waiting time of 18 weeks, | was told, was comparable to ‘cancer waiting times’. However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral. Heather was already in receipt of consultant led care. Her need was urgent. Thus such a comparator on waiting times to justify an 18 weeks wait for psychotherapy is not an appropriate measure. By letter dated 3" January 2019 Pennine Care responded to my concerns about the long waiting list as follows, “The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements.” The MATTERS OF CONCERN are as follows. — It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life, a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the help/treatment she was seeking on voluntary admission some 4 months previously. . A target waiting list of 18 weeks is far too long but | was told that this was a funding issue. Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for treatment. [6 | 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 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Heather's mother 2. Heather's partner 3. Dep Managing Director Mental Health and Specialist Services, Pennine Care NHS Foundation Trust | 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. Andrew Bridgman HM Assistant Coroner 12.02.2019
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.
• Department of Health & Social Care From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health, Inequalities and Suicide Prevention 39 Victoria Street London SW1H0EU 020 7210 4850 Mr Andrew Bridgman HM Assistant Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SKI 3AG <g"/ft_ May2019 Thank you for your correspondence of 12 February about the death of Miss Heather Louise Carey. I am grateful for the additional time in which to reply. Firstly, I would like to say how very sorry I was to read of the circumstances of Miss Carey's death. I appreciate her loss must be extremely distressing for her family and loved ones and I offer my sincerest condolences. Your report offers significant learning to the local NHS and I expect firm action to be taken by both the local commissioner and provider of services to respond to the concerns raised and the failings identified. I am aware that the Tameside and Glossop Clinical Commissioning Group (CCG) has responded to you with information on the action it is taking locally to improve access to secondary care psychological therapy. This includes the development of a new model of psychological therapy for people with complex mental health needs, as well as increased investment to support improved access to psychological therapies. In addition, the CCG is working with the Pennine Care NHS Foundation Trust to agree a Performance and Outcome Framework for 2019-20 to ensure activity, waiting times and outcomes are reported and monitored. I should make clear that the 18-week waiting time of which you were advised at inquest relates to the Improving Access to Psychological Therapies (IAPT) programme. The evidence-based psychological therapies provided through IAPT are designed to offer intervention for adults with common mental health problems, such as depression and anxiety. I would therefore like to explain the action we are taking at a national level to improve access to treatment for those with severe mental illness. The Five Year Forward View for Mental Health 1, published in 2016, recommended investment to increase access to psychological therapies for people with severe mental illness, namely psychosis, bipolar disorder and personality disorder. This ambition is reiterated and built upon in the NHS Long Term Plan2, published in January 2019. The Improving Access to Psychological Therapies - Severe Mental Illness (IAPT- SMI) sites have demonstrated the positive impact of access to NICE-recommended psychological interventions on experience, outcomes and reduced healthcare utilisation. NHS England and Health Education England are working to build on the IAPT-SMI programme and 'scale-up' so that a greater number of people have access to psychological therapy as a core component ofthe adult mental health services offer. This year, funding is being made available to test new models of community mental health care. This includes testing ways to improve timely access to courses of psychological therapies for people with psychosis, bipolar disorder and personality disorder. In addition, NHS England will test four-week waiting times to appropriate care, to help build our understanding of how best to introduce ambitious but achievable improvements to access, quality of care and outcomes. NHS England is expected to publish shortly a Community Mental Health Framework to support local areas in the transformation of community mental health services. This will include a focus on ensuring NICE-recommended psychological therapies are offered (where clinically appropriate) in the community. Finally, the NHS Long Term Plan, in accordance with the recommendations in the Independent Review ofthe Mental Health Act3 therapeutic inpatient environments which provide the best opportunity for recovery. To ensure the provision ofpurposeful, patient-orientated and recovery-focused inpatient care, NHS England is investing to improve the therapeutic skill mix of staff. For example, allied health professionals and psychological professions such as occupational therapists, psychologists and physiotherapists, as well as peer support workers will enable therapeutic interventions to be delivered more flexibly across , commits to the creation of ' https:l/www.england.nhs.uk/wp-content/uploads/2O16/02/Mental-Health-Taskforce-FYFV-final.pdf 2 hmis:llwww.longtermplan.nhs.uk/ 3 https:l/www.gov.uk/government/groups/independent-review-of-the-mental-health-act inpatient and community settings, facilitating timely, clinically appropriate discharge, as well as continuity of care pre- and post-discharge. I hope this information is helpful and provides assurance that measures are being taken to improve access to psychological therapies for those with severe mental ill health. I am grateful to you for bringing these matters to my attention. JACKIE DOYLE-PRICE
STRICTLY PRIVATE AND CONFIDENTIAL
Mr Bridgman
HM Assistant Coroner
Coroner’s Court
1 Mount Tabor Street
STOCKPORT
SK1 3AG
CHIEF EXECUTIVE &
ACCOUNTABLE OFFICER
Chief Executive, Tameside MBC
and Accountable Officer, Tameside &
Glossop CCG
Tameside One, Market Place, Ashton under
Lyne, OL6 6BH
Date 8 April 2019
Dear Mr Bridgman,
Re: Heather Louise CAREY - Regulation 28 - Prevention of Future Deaths
Further to your letter, dated 12 February 2019 and my acknowledgement, regarding the tragic
death of Heather Louise Carey, please find our response outlined below.
Clearly the untimely death of any person is distressing for the family and any others affected by
their death and loss, and all the more so if there is any belief that but for the actions of any
organisation it could have been avoided.
I would like to record my sincere condolences to the Heather Louise Carey’s family for their loss
and I hope through this process they can obtain some closure.
The Inquest identified a number of issues which likely contributed to Ms Carey’s decision to end
her life. One of those issues related to the long wait following discharge before psychotherapy
would begin.
At the time of Ms Carey’s admission to TGH there was no psychotherapy available to her as an
inpatient because there were insufficient funds available to provide the same. I understand you
were informed that this issue was being addressed by further funding being made available.
At the time of Ms Carey’s assessment on the 22 November 2018, staffing levels were reduced
through illness and vacancy and only one psychotherapist was available. That was the reason
given for the 24 week wait in excess of the target waiting list of 18 weeks, which you were advised,
was the maximum waiting time for non-urgent consultant led treatment from the point of referral.
However, Ms Carey was already in receipt of consultant led care and her need was assessed as
urgent and therefore in your opinion such a comparator was inappropriate.
Accordingly, the concern you raise is that unless adequate and sufficient measures are taken to
significantly reduce waiting times for acute mental ill health, comparable to physical life threatening
illnesses, not simply a redistribution of existing resources, more patients with mental health issues
will end their lives whilst on a waiting list for treatment.
Thank you for bringing this significant issue to my attention, I share your concerns.
1 | P a g e
The Responsible Senior Officer
Commissioning.
for
this work
is Jessica Williams,
Interim Director of
I’m advised that the following action has been taken owing to concerns raised through this case
and others, the CCG is taking forward a number of actions and in particular relating to the two
concerns you raise
1) WAITING TIMES FOR SECONDARY CARE PSYCHOLOGICAL THERAPY
a. Psychological Therapies Review - commenced in October 2018 this review focuses on
access and quality of psychological therapy services for people with more complex needs
including those under the care of the Community Mental Health Teams. The review
identified that while NICE concordat therapy services are being provided waiting times for
treatment are too long in some services.
The reviewing team are using this information alongside an exploration of alternative
models of care to develop a new model of psychological therapy for people with complex
mental health needs in Tameside and Glossop. This review will conclude by the 31 of July
2019.
b. Improving access to psychological therapy – the Tameside and Glossop Strategic
to
Commissioning Board has committed additional
psychological therapies. An additional £271,000 agreed in 2018/19 will be increased by an
additional £673,000 per annum by 2021 to meet a range of pressures.
increase access
funding
to
c.
Improving monitoring – the CCG is working with the Trust to develop a new Performance
and Quality Outcome Framework for the 2019/20 Pennine Care contract. This will ensure
that activity, waiting times and outcomes for every service are routinely reported and
robustly monitored.
d. Current performance in Secondary Care Psychological Therapies – the CCG is
advised that due to actions taken internally the current waiting times for the service have
improved, with a current waiting time for Cognitive Analytical Therapy of 13 weeks.
e. Support for people waiting for therapy – we have asked the Secondary Care
Psychological Therapy Service to ensure that that when people are advised about the
waiting times that they are supported to work with their care coordinator for stabilisation,
containment and pre therapy work in preparation for therapy to ensure that they do not
suffer the distress and despair that Ms Carey’s family state that Ms Carey experienced and
evidenced by her tragic death.
2) NO PSYCHO-THERAPY AVAILABLE TO MS CAREY DURING HER INPATIENT
ADMISSION
The CCG has invested £600,000 recurrently to improve staffing on the inpatient mental
health wards at Tameside Hospital with a focus on improving safety, patient experience and
outcomes. The Trust has invested this funding in improving the skill mix of the teams,
including additional clinical psychology and occupational therapy, as well as nursing and
admin. The CCG is formally monitoring the impact of this investment through regular Safer
Staffing Reports presented to the Pennine Care Quality Group. Reports from staff on the
Tameside wards and the latest CQC report indicate that this is having a positive impact.
We shall keep this issue under review as part of the quality monitoring reported to the Strategic
Commissioning Board, whose meetings are held in public.
2 | P a g e
I hope this brings some reassurance that we are working to ensure another tragic loss of live
doesn’t occur in similar circumstances.
Please contact me if you require any further information or if I can assist further in any way.
Yours sincerely,
Chief Executive, Tameside MBC
and Accountable Officer, Tameside & Glossop CCG
3 | P a g e
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