Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0069, written 27 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 | 27 Feb 2019 |
|---|---|
| Reference | 2019-0069 |
| Deceased | Peter Garvin |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Organisation named | Central and North West London NHS Foundation Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Claire Murdoch, Chief Executive Officer, Central and North West London NHS Foundation Trust, Trust Headquarters Executive Office, 350, Euston Road, London. NWI1 3JN Simon Stevens, Chief Executive, NHS England, Skipton House, 80 London Road, London. SE1 6LH 1 | CORONER | am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London 2 | 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. 3 | INVESTIGATION and INQUEST On the 5"" January 2019, evidence was heard touching the death of Peter George Garvin. Mr Garvin, had entered the Regent's Canal in Westminster on 31%! January 2018, with the intention of taking his own life. He was 86 years old at the time of his death. The findings of the court were as follows: Medical Cause of Death 1 (a) Drowning How, when and where the deceased came by her death: Mr Garvin was suffering with a second episode of treatment resistant depression. He had previously attempted to take his own life in October 2017. At or around 10:35 on 31 January 2018 he entered the Regent's Canal in Westminster with the intention of taking his own life. There was no third party involvement. He was recovered and recognised as life extinct at 12:27. Conclusion of the Coroner as to the death: Mr Garvin took his own life whilst suffering with depressive illness. Circumstances of the death. At the time of his death Mr Garvin was under the care of the Community Mental Health Team, however his medication was being prescribed by his GP. There were intermittent communication problems between the CMHT and the GP re his prescribing. In October 2017 he had required admission but due the lack of local beds he had been hospitalised in Milton Keynes. Mr Garvin's illness placed a lot of strain on his elderly wife, but she was not offered a carer's assessment prior to his death. His illness was treatment resistant, and he asked for private psychiatric assessment in a search of a cure. He saw a private psychiatrist on 19th January 2018. When the CMHT became aware that he had sought private treatment he was informed that he would be discharged from the CMHT. He was informed of this by his CPN at a home visit of 29"" January 2018. This had a significant adverse effect on his mood. Just two days later, he took his own life. It is the policy of Mr Garvin’s consultant to discharge patients from NHS care if they are taken for private treatment, apparently due to concern over potential communication difficulties. The private psychiatrist stated in evidence that she could only have seen Mr Garvin intermittently in out patients which in her view he was too ill for, or admit him to hospital. This would have deprived Mr Garvin of the option of being cared for at home in the community. Concerns of the Coroner: 1. That there should be a system of doctor to doctor communication to facilitate prescribing, for example through direct email contact. 2. That there should be sufficient local beds so that such a vulnerable person should not have to be hospitalised so very far from home. 3. That if patients seek private psychiatric care they should not be discharged by the NHS. Instead a memorandum of understanding should be agreed between the NHS and Private psychiatric consultants to allow joint working and facilitate patient care. This should surely be possible along the lines of such agreements with GPs. 4. That carer's assessment should be undertaken early in the patient treatment pathway. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. |, 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 : —_ tant We chick Community Mental Health Team, 190, Vauxhall Bridge Road, London. SW1V 1DX Nightingale Hospital, 11-19 Lisson Grove, Marylebone, London. NW1 6SH General Practitioner, St Johns Wood Medical Practice, Brampton House, Hospital of St John and St Elizabeth, 60, Grove End Road, London. NWé8 9NH | 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. 27" February 2019 Professor Fiona J Wilcox HM Senior Coroner Inner West London Westminster Coroner’s Court 65, Horseferry Road London SW1P 2ED Honorary Professor QMUL School of Medicine and Dentistry
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.
7 INHS Central and North West London NHS Foundation Trust 6 May 2019 Professor Fiona J Wilcox HM Senior Coroner Inner West London Westminster Coroner Court 65 Horseferry Road London SW1P 2ED Dear Professor Wilcox, Re: Regulation 28 Report Following the Inquest into the Death of Peter George Garvin Further to your letter dated 24 April 2019, | am sorry that this response has taken some time but we were keen to ensure that we fully addressed your concerns. Because of the Trust’s location and geography we can potentially be working with any number of private psychiatrists which would make it impossible to have a standard MOU agreed by all of them in advance. As an alternative, we have drawn up a protocol for our own staff, which sets out (a) how they should work with colleagues working in any private sector organisation and (b) how they should explain the process to their patients. This draws heavily on national guidance. | hope this addresses the concern that you raised. | know that you will be meeting with our Medical Director soon and | hope this will provide an opportunity to discuss any remaining issues on concerns that you may have. Yours sincerely, e Claire Murdoch pr C _ Chief Executive tl” YP ee ian 4 Trust Headquarters, 350 Euston Road , London NW1 3AX Telephone: 020 3214 5700 www.cnwi.nhs.uk La-44 Pe lA/ hop SP ¢g \ Ppp naa Wellbeing for life eMPOWERMENT PARTNERSHIP London | Milton Keynes | Kent | Surrey | Hampshire INHS| Central and North West London NHS Foundation Trust Guidance for staff when a patient wishes to seek advice or treatment from a private clinician Core principles 1. Process The Department of Health has issued guidance (ref below) clarifying that if a patient opts for private care their entitlement to NHS care remains and should not be withdrawn. The guidance also makes clear that there must be as clear a separation as possible between a patient’s private treatment and their NHS treatment. Patients can choose to return to NHS care at any point and are entitled to NHS services on exactly the same basis of clinical need as any other patient. When advising patients or patients’ representatives on additional private care, doctors should respect the patient's right to seek a second opinion, as set out in the GMC’s Good Medical Practice guidance (2006). Effective communication about treatment options should be maintained at all times. Any situations where patients receive additional private care alongside NHS care should be handled with the highest standards of professional practice and clinical governance. When a patient requests private care the treating NHS clinician should discuss with the patient the options open to them including informing them of the risks and benefits of their requested course of action. If the treating clinician is concerned that there is a risk to patient safety and conflicting care approaches by having two simultaneous providers this should be explained to the patient and plans put in place to ensure safe handover of care. Transferring between NHS and private care should be carried out in a way which avoids putting patients at any unnecessary risk. The NHS and the private provider should work collaboratively to put in place protocols to ensure effective risk management, timely sharing of information, continuity of care and coordination between NHS and private care at all times The patient should be made aware that they are able to return to our care at any point if they choose to do so and be made aware of how they would do this. An NHS guide for patients can be accessed on this link: https://www.nhs.uk/common-health-questions/nhs-services-and-treatments/if-i-pay-for- private-treatment-how-will-my-nhs-care-be-affected/# Department of Health (2009) Guidance on NHS Patients who wish to pay for additional private care. Gateway Reference 11512, 23 March 2009. Trust Headquarters, 350 Euston Road , London NW1 3AX Telephone: 020 3214 5700 www.cnwl.nhs.uk e?%e “8 Wellbeing for life EMPOWERMENT PARTNERSHIP London | Milton Keynes | Kent | Surrey | Hampshire
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