Aryan Akhgar

Regulation 28: REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO: 

1.  The Medical Director, The Sheffield Children’s Hospital 
2.  The Chief Executive, Sheffield Health and Social Care Trust 

1  CORONER 

Stephen Eccleston, Assistant Coroner for the area of South Yorkshire (West) 

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 9th March 2018, I commenced an investigation into the death of Aryan Akhgar aged 17. The 
investigation concluded at the end of the inquest on 25th January 2019. The conclusion of the 
inquest was: 

Narrative Conclusion 

Aryan Akghar died on 06.03.18 in the Northern General Hospital Sheffield following an incident on 
16.02.18 when he hanged himself from a self‐administered ligature with the intent to take his own 
life. 

Aryan’s death occurred against a background of four serious attempts to take his own life on 
03.01.18, 06.01.18, 09.01.18 and 11.01.18. Aryan was assessed on 09.01.18 by specialists from the 
Adult Mental Health Trust in the Northern General Hospital Sheffield and discharged home to his 
family. That assessment recommended an urgent response and visit the next day by the Home 
Treatment Team. The Home Treatment Team declined the referral because Aryan was under 18. 
The STAR team in CAMHS did not at that time provide an urgent response service. The first visit by 
mental health professionals to Aryan therefore was not until 15.01.18 because of this gap in 
provision.  

Aryan was seen by the STAR Deliberate Self Harm team on 15.01.18, 21.01.18 and 03.02.18 and 
was then discharged. Aryan then hanged himself on 16.02.18. 

 
 
 
 
 4  CIRCUMSTANCES OF THE DEATH
Please see the narrative conclusion set out in box 3. 

Aryan’s medical cause of death was due to hanging. All witnesses accepted that there was a gap 
in services for Aryan and, notwithstanding the evidence of the Medical Director of the Sheffield 
Children’s Hospital, I remained concerned that the referral criteria for different teams for children 
and adults may result in a young person in Aryan’s circumstances falling between a gap between 
different services. 

5  CORONER’S CONCERNS 

The MATTERS OF CONCERNS are as follows: 

5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues, 
such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health 
input, commencing the next day. This was not available as a service for under 18’s in Sheffield and 
so a referral to Adult Mental Health Services was made in order to obtain this. The adult service 
refused to take the referral because Aryan was still a child. This gap in the provision between the 
two services meant that Aryan did not receive the urgent mental health input which he required 
and there is a risk that other under 18’s in his situation might also suffer the same problem. 

 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. 

7 YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 29th May 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 family of Aryan Akhgar 
(Interested Persons). I have also sent it to The CQC who may find it useful or of interest. 

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. 

 
 
 
 
 
 Steve Eccleston 

Assistant Coroner for 
South Yorkshire (West) 
Dated: 3rd April 2019

Working with you-to make Sheffield ote oe ;
ERECLIWER SE 7 Sheffield Children’s [Zr

aD
FER | NHS Foundation Trust

30 MAY 2019
Sheffield

eee oa CICE
Clinical Commissioning Group

29 May 2019
Our Ref: JS/JU/Eccleston2 CCG 23-5-19 Western Bank
: Sheffield
S10 2TH
Mr Stephen Eccleston ee
Assistant Coroner for South Yorkshire (West) www.sheffieldchildrens.nhs.uk
The Office of H.M Coroner ’
The Medico- Legal Centre ; 722 Prince of Wales Road
Watery Street Darnall
Sheffield ; Sheffield

Dear Mr Eccleston,

Following your recent Regulation 28 Report to Prevent Future Death issued on 3rd April
2019, please find detailed below the joint response from NHS Sheffield Clinical
Commissioning Group and Sheffield Children’s NHS Foundation Trust.

The MATTERS OF CONCERN and the Trusts’ responses are as follows:

5.1. A gap in services was identified for 16 and 17 year olds with urgent mental health
issues, such as Aryan had. On 9" January 2018, Aryan was assessed as requiring
urgent mental health input, commencing the next day. This was not available as a
service for under 18’s in Sheffield and Aryan did not receive any contact from Child
and Adolescent Mental Health Services (CAMHS) until 15 January 2018. In
evidence | was told that additional resources in the CAMHS service were close to
agreement in order to prevent this kind of problem arising in the future. However, this
would be subject to a commissioning process from the Clinical Commissioning Group
for Sheffield which could not be guaranteed.

5.2 /twas accepted in evidence by the Medical Director of Sheffield Children’s Hospital
on behalf of CAMHS that such additional resource was required. The delivery of the
necessary funding to properly resource the CAMHS team was not guaranteed.

Sheffield Children’s NHS Foundation Trust and NHS Sheffield Clinical Commissioning
Group have been working collaboratively to develop a robust long term solution to the
issues you have highlighted. The two organisations have considered the potential models
and have agreed the most appropriate way forward to be through the reconfiguration of
the existing Sheffield Treatment and Recovery (STAR) Service into a CAMHS Home
Intensive Treatment Team (HITT).

k it Mag, The
yenn Somers SV S Nonneae: V/s cyistens Sarah Jones
Chief Executive Standard “Osa Charity Chair
*

This new team will be responsible for children and young people up to the age! of 18 years
and will be aligned with, and where appropriate, undertake, joint working with the Home
Intensive Treatment Services provided by Sheffield Health and Social Care NHS
Foundation Trust. In addition the Mental Health Liaison Team will support 0-18 year olds
attending either Sheffield Children’s or the Northern General Hospital’s Emergency
Departments. Access to the HITT will be within 24 hours when required whilst the Liaison
Team will operate to meet the demands through the Emelgenty Departments with an on
call rota in place for out of hours.

At the time of writing, the business case for the HITT team has been completed and was
approved by the CCG on 7 May 2019, with a plan to begin a phased implementation
from the autumn 2019. The service will be evaluated to ensure that it meets the needs of
the young people who are its. service users.

The CCG and the Trust recognise that there is urgency to the situation and are working
closely to ensure that there is no delay to its implementation noting also the temporary
change in pathway agreed between Sheffield Children’s NHS Foundation Trust and
Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has
already begun to recruit nursing staff to the new service in anticipation of its formal
commissioning.

Both the CCG and the Trust acknowledge the significant impact the gap in service
provision has had in this case and are both fully committed to work together to make
lasting and tangible improvements in service delivery.

We trust this response addresses the matters of concern you have raised with us.

Yours sincerely,

John Somers

Acting Accountable Officer Chief Executive

NHS Sheffield CCG Sheffield Children’s NHS Foundation Trust
A Sheffield Sys child % ‘

John Somers arian BA ren's Sarah Jones

Chief Executive S VS Staawiaed say Hospital ; Chair

Charity.

NHS) | Sheffield Children’s [/Z53

Sheffield Health
NHS Foundation Trust

and Social Care
NHS Foundation Trust

Western Bank

Fulwood House Sheffield
Sheffield : $10 2TH
$10 3TH

P| www. sheffieldchildrens .nhs.uk
28 May 2019

Our Ref: JS/JU/Eccleston1 23-5-19

Sent via email and post

Mr Stephen Eccleston

Assistant Coroner for South Yorkshire (West)
The Office of H.M Coroner

The Medico- Legal Centre

Watery Street

Sheffield

$3 7ES

Dear Mr Eccleston

Following your recent Regulation 28 Report to Prevent Future Deaths issued on 3” April
2019, please find the details of the joint response from Sheffield Health and Social Care
NHS Foundation Trust and Sheffield Children’s NHS Foundation Trust.

The MATTERS OF CONCERN and the Trusts’ responses are as follows:

5.1 A gap in services was identified for 16 and 17 year olds with urgent mental health
issues, such as Aryan had. On 9"" January 2018, Aryan was assessed as requiring
urgent mental health input, commencing the next day. This was not available as a
service for under 18’s in Sheffield and so a referral to Adult Mental Health Services
was made in order to obtain this. The adult service refused to take the referral.
because Aryan was still a child. This gap in provision between the two services

' meant that Aryan did not receive the urgent mental health input which he required
and there is a risk that other under 18’s in his situation might also suffer the same
problem.

Sheffield Children’s and Sheffield Health and Social Care Trusts have been working
collaboratively to provide robust solutions to the gap in service provision. We would like to
draw out the following actions in particular to give assurance that we have responded
definitively and quickly to ensure that a safer, more effective response is given to young
people experiencing mental health crises in the city.

at 449,

John Somers SVS fvckiaitsel VV ba et He Sarah Jones
Chief Executive Standard Chair

e
sayy

1. An addendum to the Transitions Policy has been jointly approved by both Trusts
that ensures that emergency home treatment will be provided to 16/17 year olds by
Sheffield Health and Social Care’s adult services, should they require crisis
intervention out of hours and where they are not known to Child and Adolescent
Mental Health Services which mirrors that already present for those known to the
Services. This was implemented with effect from January 2019.

2. To ensure a process of continuous learning and development, there will be a review
of the care and treatment of any young person accessing care as described above.
Written summaries of their care will be produced, and a review will be personally
overseen by the Associate Director in Sheffield Children’s and the Director of
Operations and Transformation in Sheffield Health and Social Care Trust. This was
implemented with effect from February 2019. Up until the end of April 2019 no
patients have accessed the service through this route.

3. To provide improved access to and sharing of relevant clinical information between
the two Trusts, it has been agreed that Sheffield Health and Social Care staff
working in the crisis assessment and home treatment team will have ‘read only’
access to electronic patient records for CAMHS activity at Sheffield Children’s.

This has been in place from 1* April 2019, following implementation of ‘SystmOne’

electronic record solution at Sheffield Children’s CAMHS. Service leads from both

Trusts are working collaboratively to ensure that additional staff training is delivered
by the end of June 2019, so that revised process workflows are embedded, i.e. to

maximise the use of the shared clinical information where required.

The Trusts acknowledge the significant impact the gap in service provision has had in this
case and are both fully committed to work together, and with NHS Sheffield Clinical
Commissioning Group (CCG) to make lasting and tangible improvements in service
delivery.

We trust this response addresses the matters of concern you have raised with us.

_ Yours sincerely

1 \ “~— —~—

Kevan Taylor John Somers
Chief Executive Chief Executive

Enc: Action Plan

John Somers SVS VGIMRER iYYS ers Sarah Jones
Chief Executive Standard RS Sse - Chair