Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0057, written 19 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 | 19 Feb 2019 |
|---|---|
| Reference | 2019-0057 |
| Deceased | Janice Keelan |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 This report is made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Recipients This report is being sent to: Ms Joanne Roney — Chief Executive, Manchester City Council (MCC) > BRINE. City Sotitor, mc e Dr Chris Daly —- Medical Director, Greater Manchester Mental Health NHS Trust Coroner | am Nigel Meadows, HM Senior Coroner for the area of Manchester City. 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 On 21 November 2017 | commenced an investigation into the death of Janice Andrea Keelan, aged 48. The investigation concluded at the end of the inquest on 14 February 2018. The cause of death was found to be: ja Drowning The conclusion of the inquest was Accidental Death. Circumstances of death The deceased was a 48 year old single person who suffered from chronic and complex health conditions. She had been diagnosed over a long period of time with a vanety of conditions including schizophrenia; affective psychosis; schizoaffective disorder recurrence in puerperium; paranoid depression; bipolar affective disorder and Korsakoff’s syndrome. Her most recent medications were Depakote in tablet form; Risperidone in tablet form, Promethazine in tablet form and Risperidone Conta administered as a fortnightly depot injection. Toxicology tests showed that she had not consumed alcohol or taken an overdose of her medications, and only a small amount of Promethazine was detected which was consistent with therapeutic use. There were no traces of her antipsychotic medications and this may indicate that she had not recently taken these tn tablet form and that she was due to have a further injection of her depot medication. She lived 2 ee her adult daughter, who was acting as her primary carer. She died on ovember 2017. In the days before she died, her daughter noticed a deterioration in her mental state and she seemed to be responding potentially to auditory and visual hallucinations. From the beginning of the year, her daughter had noticed that on occasions she would fall asleep in the bath. The deceased’s medication also had the effect of making her sleepy or drowsy. The nature of her mental health disorders meant that she was prone to relapses which occurred not infrequently. Her daughter was concerned that her mother could possibly fall asleep in her bath and drown. It was reported that in June 2017 she suffered a witnessed seizure and was admitted to hospital. No treatment was required and she was discharged back to her GP, who reviewed her in July and actually considered the event in the bath was likely to be a vasovagal episode. Nonetheless, she was referred to the First Fit clinic but did not attend. As a consequence of the deceased’s daughter’s concerns for her mother’s welfare in the bath, a referral was made to MCC in order for her bath to be removed and replaced with a walk-in shower. The referral was received, it seems, in May or June 2017, but was allocated to a primary assessment officer on 7 July 2017, who attended the deceased’s home on 21 July 2017. This visit coincided with the attendance of a Community Psychiatric Nurse (CPN) in order to administer the deceased’s regular injection of antipsychotic medication. Her daughter was also present. The CPN told the MCC assessor that she was concerned that the deceased has recently scalded herself in the bath and has recently experienced seizures. Her daughter also reported that the deceased’s ‘medication makes her drowsy and she has found her asleep in the bath on several occasions and she is frightened that her mum will drown’. The assessor records in the assessment document: ‘I have advised she does not use the bath and | will make a referral to MSIL to request a walk-in shower assessment.’ The assessment was then passed on to the assessment team manager for progression. By 11 August 2017, an advanced assessment officer had visited the deceased and confirmed she met the eligibility criteria for the bath to be removed and for a wet room/shower to be installed. The assessment team manager authorised the assessment and sent it on 25 August 2017 to the ‘Major Panel’. [n practical terms, this resulted in her referring the matter to herself, because she was the sole member of ‘the Panel’. This triggered an MCC technical team assessment, which was allocated to a technical officer on 6 October 2017 and finally approved on 24 November 2017, ten days after the deceased died. 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. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare. The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal. Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic. Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms There was also clear evidence that the deceased had scalded herself in the bath. She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using abath. This added to the risks to the deceased. 2. It was understood that there was some form of prioritisation process for dealing with these sort of cases, although it was not entirely clear at the inquest hearing how this actually worked, specifically and in detail in practice. The process in this case clearly required urgent prioritisation because of the obvious and apparent risk of death, which MCC were told about at the outset. 3. It does not appear that following the death of the deceased, there has been any internal review or reflection by MCC about the processes involved in this case, or the need to address changes to the prioritisation criteria. 4. The death was potentially avoidable. If for practical reasons the work simply could not have been done prior to 14 November 2017, contact could have been made with the mental heaith team seeking assistance and advising them of the position so that they could take steps to intervene in order to minimise the risk of a fatality. Sadly, the deceased died just as her daughter feared she might and that is why the application had been made in the first place Action should be taken In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. 1. The above four numbered paragraphs set out the issues which need to be addressed Your response You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 April 2019 |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: e The deceased’s daughter e The deceased's sister e The deceased's niece | am also sending a copy to the Medical Director of the Mental Health 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. N Meadows 19 February 2019 H.M. Senior Céroner — Manchester City area
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.
City Solicitor
PO Box 532
Town Hall Manchester M60 2LA
DX 714441 Manchester 1
Tel: 0161 234 3006
Your ref: J. Keelan (deceased)
Our ref: SSV5002/1954
Date: 16 April 2019
Mr Nigel S. Meadows
H.M. Senior Coroner
H.M Coroner’s Office
Manchester City Area
Exchange Floor
The Royal Exchange
Cross Street
Manchester
M2 7EF
Dear Mr Meadows,
Janice Keenan (deceased). Response to Regulation 28, Inquest dated 14th
February, 2019.
Thank you for your Regulation 28 Report dated 19 February 2019.
I will address the issues you raise paragraph 1 – 4. In order to do this, Manchester City
Council (the Council) co-ordinated a Review on 1st April 2019. The Council is
committed to learning from this very sad death.
Issues to be addressed at paragraph 1:
1. Fluctuating and impaired cognition:
The Council has now ascertained that the deceased was not care co-ordinated
by Greater Manchester Mental Health Trust (GMMH). The deceased had been
cared for by a ‘Lead Professional’ from GMMH. This means she would be
administered a depot injection every two weeks, either at home or at the depot
clinic. At the Review, the Council was informed that in January, April and June
2017, her Lead Professional, asked for the deceased to be escalated to a
Community Mental Health Team, as the Lead Professional considered that the
deceased needed a more comprehensive mental health service.
Providing a legal service for Manchester City Council and Salford City Council.
2. When the GMMH Lead Professional met with the Council’s Primary
Assessment Team (PAT) on the initial assessment on 21st July 2018, neither
party recognised that there was an issue about the deceased’s mental capacity.
At that stage, a mental capacity assessment should have been conducted. The
outcomes from such an assessment would have informed whether or not the
deceased could make her own decisions about bathing. Another opportunity
was missed in August, when an Occupational Therapist visited the deceased.
As you quite rightly point out, to suggest that the deceased should desist from
having a bath was unrealistic. It is clear that the deceased had been taking a
bath during the night, again as you point out, she had complex needs which her
daughter had managed for years.
Learning:
The Council has devised an Action Plan, which is attached and which
highlights:
1. A recognition that there is a need for multi-agency training for all agencies to
ensure co-ordination and clarity around decision making for people with
complex needs.
2. A recognition that had a mental capacity assessment been conducted, it is
unlikely this would have been shared across organisations.
3. That although a Carer’s assessment of the deceased’s daughter had been
completed by GMMH, the Council was not aware of that.
Action:
1. Mental Capacity Awareness Training to be reviewed to ensure clarity around
Complex decision making.
2. A Safeguarding Adults referral for consideration to whether a Safeguarding
Adults Review (SAR) is required pursuant to s 44 Care Act 2014. To be co-
ordinated and undertaken to examine this case and its implications. The
purpose to consider whether a SAR referral is required (Learning across the
partnership).
The Manchester Safeguarding Adults Board (MSAB) will consider undertaking a
SAR when it is known or suspected that:
a) Actions or omissions in a number of agencies involved in the provision of
care, support or safeguarding of an adult, or group of adults, at risk of abuse or
neglect have caused or are implicated in the death or serious harm of that
individual or group of individuals.
or
b) An adult or group of adults at risk die or experience serious harm and there
are concerns about how agencies have worked together to prevent, identify,
minimise or address that harm and there are concerns about how this may place
other adults at risk of serious harm.
and
c) There are clearly identified areas of learning and practice improvement or
service development that have the potential to significantly improve the way in
which adults at risk of abuse and neglect are safeguarded in the future.
The SAR subgroup of the MSAB will consider the issues raised within the case
and will carefully examine the potential for learning across agencies/services.
Issues to be addressed at paragraph 2:
Manchester’s Service for Independent Living (MSIL)’s prioritisation criteria has been
reviewed with the fundamental principal of improved communication within the service.
What this means is that the service will allocate resources in line with need. In
addition, all those on waiting list we will review on a regular basis, identifying those
who are at risk and intervening in a timely manner.
Learning:
It is essential that we have a continuous overview of our citizens’ wellbeing, if people
relapse, become unwell or have adverse life events, such as carer breakdown, the
service needs to be able to intervene immediately. The waiting list will now be
managed i.e. citizens will be contacted on a regular basis and be continually
reprioritised if necessary.
Action:
Implement overview and assessment of MSIL’s waiting list, agreeing a prioritisation
process, this will be overseen and implemented by the Head of Service for this
service. This will be implemented by 30th May 2019.
Issues to be addressed at paragraph 3
GMMH conducted a local 3 day review and a formal review and informed the Council’s
our review: The Council Led action plan is attached.
Learning:
There are agency escalation processes in place for high risk cases but further work is
required to ensure adherence.
Action:
The Council/GMMH review of agency escalation processes.
Issues to be addressed at paragraph 4
1. Neither the Council nor GMMH has had ready access to the other’s notes
2. Previously there was limited co-working between the two organisations.
Learning
The Council and GMMH should have had an overview of the deceased’s well-being.
Action:
At the monthly partnership/organisational meeting between the Council and GMMH,
there will be standing items on the agenda covering effective joint working and
information sharing.
I hope that the above properly addresses all of the issues raised in your report. However,
if there is any matter upon which you would like clarification, please do not hesitate to
contact me.
Yours sincerely
Joanne Roney
Chief Executive
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