Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0137, written 23 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Apr 2019 |
|---|---|
| Reference | 2019-0137 |
| Deceased | Kerry Hunter |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive, Norfolk and Suffolk NHS Foundation Trust, 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 10th May 2016 I commenced an investigation into the death of Kerry Hunter The investigation concluded at the end of the inquest on 4th April 2019. The conclusion of the inquest was that of; Suicide The medical cause of death was confirmed as: 1(a) Bronchopneumonia. 1(b) Hypoxic brain injury. 1(c) Insulin overdose. 4 CIRCUMSTANCES OF THE DEATH Kerry Hunter died as the result of an overdose of insulin medication she administered to herself on the 9th April 2016. Kerry was found unconscious at her home address by her father and transported to the Ipswich Hospital, Heath Road, Ipswich where she deteriorated over a period of time. She tragically passed away at the Ipswich Hospital at 04.30 on the 1st May 2016. Kerry had a significant history of previous suicide attempts and for a long period of time was receiving treatment from the Norfolk and Suffolk Foundation Trust. Kerry was diagnosed as having Borderline Personality Disorder and her most recent suicide attempt occurred on the 31st March 2016 nine days prior to being found unconscious at her home. Prior to her death Kerry had requested a specific form of treatment for her Borderline Personality Disorder called Dialectic Behavioural Therapy. Although, this treatment was available and Kerry would have been a suitable candidate, this was not recognised at the time and therefore the treatment was not provided by the Norfolk and Suffolk Foundation Trust. Whether or not the provision of Dialectic Behavioural Therapy would have prevented Kerry’s death could not be established on the available evidence. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you; the MATTERS OF CONCERN as follows:- It was heard in evidence that since Kerry’s death the Norfolk and Suffolk Foundation Trust have conducted a review of their treatment provision for individuals suffering from Borderline Personality Disorder (BPD). As a result of this review the Norfolk and Suffolk Foundation Trust are planning to move the Borderline Personality Disorder Service treatment in-house rather than using external providers and will provide Dialectic Behavioural Therapy This change is currently in the planning stage and at the hearing I formally requested an update when these plans are put into practice. The update is to include details the new policies and procedures in place regarding clarity of communication of information given to those suffering with BPD, the training and development of Norfolk and Suffolk Foundation Trust staff in relation to BPD and the undertaking of formal risk assessment and the completion to the requisite documentation in cases of those suffering with BPD. During the hearing itself evidence was heard from an expert witness ) about one of the facets of those suffering from BPD which was not addressed by the NSFT plans. Under the proposed new system, in order to access the Norfolk and Suffolk Foundation Trust Borderline Personality Disorder service, those suffering from the condition would have to agree to be transferred for treatment under the Norfolk and Suffolk Foundation Trust Integrated Delivery Team for onward referral to the new bespoke service. However, explained that the majority of individuals with a diagnosis with BPD will have had significant previous contact with their mental health service providers. Kerry herself, had had significant history of previous treatments over a number of years (including Cognitive Behavioural Therapy, Cognitive Analytical Therapy, anti- depression medication and anti-psychotic medication), none of which had proved effective. confirmed that none of these treatments would have been likely to have had a positive therapeutic effect, which in itself would compound the nature of BPD itself. explained that the cycle of being offered ineffective treatment would enhance the loss of hope and optimism which is a feature of BPD. Another facet of BPD was often an avoidant personality making sufferers unwilling or unable to engage with new individuals or teams. This being the case, I am concerned that the proposed requirement in the Norfolk and Suffolk Foundation Trust plan (which will require a BPD suffer to agree to a transfer to an Integrated Delivery Team before being placed onto the new service) may prevent some patients gaining the access to the treatment they clearly need. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 20th June 2019. I, the Senior Coroner, may extend the period if I consider it reasonable to do so. 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 Person, I am 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 25th April 2019 Nigel Parsley
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.
Our Ref: JW/ML Private and Confidential Mr Nigel Parsley Senior Coroner for Suffolk The Coroners Court and offices Beacon House Whitehouse Road Ipswich IP1 5PB Dear Mr Parsley Re: Ms Kerry Hunter Trust Management 1st Floor Admin Hellesdon Hospital Drayton High Road Hellesdon Norwich NR6 5BE 25 June 2019 I write in response to your prevention of future deaths report dated 25 April 2019 following the conclusion of the inquest into the death of Ms Kerry Hunter. I know you will share a copy of this response with Kerry’s family and I would like to express my condolences for their loss. Kerry’s death is a tragedy and it is essential the Trust takes all opportunity to learn. The report referenced the work the Trust is doing to develop the treatment provided to those who suffer from a personality disorder. It noted the evidence provided at the inquest that people eligible for this treatment would be required to transfer to the Trust’s Integrated Delivery Team in order to be referred to this service. Currently care for people with personality disorder is provided by the Trust’s community mental health teams and integrated delivery teams, where clinical psychologists either carry out therapy directly or supervise care coordinators. Some psychologists are trained in Dialectical Behaviour Therapy (DBT) methods but there are no teams that operate as a full DBT model. When a full DBT package of treatment is required, service users are referred to independent or external NHS services funded by Clinical Commissioning Groups. There is an independent sector unit in Norfolk and others around the country. There are no specific outpatient external/private DBT providers. The plan for the new Personality Disorder Service involves eight elements: 1. Clinically-led personality disorder leadership team supporting a change in culture and clinical practice at a senior level modelling consistency, accountability and leadership. 2. Improved access and assessment that involves a needs-based screening process which works alongside diagnostic criteria to ensure people access the part of the pathway which will deliver the most benefit and prevent unnecessary admissions to hospital. 3. Specialist personality disorder therapy teams comprising nurses, psychologists, psychiatrists, occupational therapists and social workers within local teams, delivering targeted interventions to those with the most complex needs and providing advice & consultation to their colleagues and the wider system. 4. A breadth of training ranging from Knowledge and Understanding Framework (KUF) training for all staff, through to full Dialectical Behaviour Therapy training for the specialist teams. Chair: Marie Gabriel CBE Chief Executive: Professor Jonathan Warren Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE Tel: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk 5. 72 hour inpatient protocol providing purposeful, formulation-driven, recovery-focused care packages concentrated on self-regulation and discharge. Linked to the screening process in order to ensure only those with a need access this level of intervention. 6. Needs-based interventions involving a framework of delivery that works with diagnosis to enable better management of people with personality disorder in standard community and inpatient pathways. 7. Crisis support through integrated working with local crisis teams and crisis cafes/hubs to deliver the needs-based model including personality disorder-specific training. Supporting teams with positive care planning to better support people in the community and improve their health outcomes. 8. Peer Support Workers to model hope and recovery, providing a vital link between statutory and third sector services and supporting the individual throughout the pathway with a focus on life beyond service engagement. The strategy has started with the recruitment into the post of personality disorder strategy lead, who will be supported by an implementation team covering the next twelve months. Where someone with a complex presentation is seeking recovery, they will be encouraged to engage with the specialist personality disorder therapy teams because of their enhanced skills and knowledge. However, it is recognised that people will have contact with other services that the Trust provides. This includes our acute hospital liaison services and Wellbeing service. We are clear, in line with national guidance and best practice, that the presentation or diagnosis of a personality disorder is not a diagnosis of exclusion which is why training will be aimed at all staff and access available to specialist advice. These services will continue to be available based upon the presenting needs of the service user. As we implement the service we will have regular review points to assess the impact both in terms of outcomes but also in respect of areas such as the access route. This will help inform adjustments in order to provide an effective service. Thank you for providing this report to the Trust. Yours sincerely Jonathan Warren Chief Executive
Private and Confidential Mr Nigel Parsley Senior Coroner for Suffolk The Coroners Court and offices Beacon House Whitehouse Road Ipswich IP1 5PB Dear Mr Parsley, NSFT Trust Management Norfolk and Suffolk Foundation Trust County Hall Martineau Lane Norwich NR1 2DH 29 January 2024 I write to update in respect of the Prevention of Future Deaths (PFD) report made in the case of Kerry Hunter in April 2019. I have discussed this with our Trust lead for personality disorder and complex needs who has provided the updates below. In response to the initial PFD questions: “Details of new policies and procedures of clarity of information given to people with BPD” Through service user involvement, we are co-producing as much of our patient-facing information about our pathways and interventions as possible. We have “Working Together Groups” and other avenues for gaining service user feedback and ideas around unmet needs, service improvement, information and policies. We are currently reviewing our personality disorders and complex emotional need (PD/CEN) strategy for release in April 2024 after service user and carer consultation. There is also a system-wide “Pathway Integration Meeting” in place which any provider can attend which improves system knowledge about what support and intervention is available in different provider organisations. “Training and development of staff in NSFT in relation to BPD” The trust continues to roll out a comprehensive training programme for NSFT staff in relation to PD/CEN. The main training for staff is our Knowledge and Understanding Framework, which is entirely co-produced and co-delivered. We also have a two-day dialectical behaviour therapy (DBT) skills course which any member of staff can attend. Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH Web: www.nsft.nhs.uk - 2 - Numbers trained to date 22 145 13 999 471 195 9 345 18 Course Crisis Plus DBT Practitioner level MBT Practitioner DBT skills level ADDRESS MBT skills SCM basic KUF Carers for PD Awareness In addition, staff in CFYP, Adult and Older Adult services have been able to train in evidence-based therapies like Mentalisation-Based Therapy (MBT) and Dialectical Behaviour Therapy (DBT). This has been supported by CCG funding and latterly by NHSE funding. As a result, most clinical areas for working age adults and youth have a full programme of at least one evidence-based therapy, and a tiered approach depending on severity and complexity. We are currently developing a specific offer for older adults with complex emotional need, supported by specific training. “Formal risk assessment and completion of requisite documentation in cases of people with BPD” We deliver STORM skills training (self harm and suicide prevention training) as our main training on risk and safety planning for clinical staff. This was piloted in Suffolk CFYP and is now being rolled out trust wide. Like other trusts, in response to national guidance, we are moving away from actuarial approaches to risk and instead focus on collaborative risk formulation and safety planning. STORM training includes specific training on safety planning, and our Dialog+ care planning tool is used to collaboratively create a safety plan for every adult and working age adult under our care. Our Youth teams have formed their own safety planning documentation which is co-produced with our young service users. Every service user will receive a co-produced safety plan. Concern around stepping up and down: In the PFD in relation to Kerry Hunter, it was stated that “those with BPD would have to agree to be transferred for treatment from the Integrated Delivery Team to the new service and it was noted by the expert witness, that many service users will have had significant previous contact with mental health services”. We have upskilled and increased the staffing resource within community teams so that service users now have improved to access evidence-based treatment. This means that service users do not have to be referred on to a specialist service or face transitions of care in order to access specialist treatment. Where teams have not been able to support a full programme of an evidence-based therapy (like DBT), there are partial programmes in place. Within primary care, we are supporting our Mental Health Practitioners (MHPs) to offer evidence-informed approaches, and we are working to expand the availability of psychological therapy to close the gap between primary and secondary care. We recognise that transitions of care can be difficult for our service users, and seek to have a “no wrong door” approach across the system, so that service users can access the right care, wherever they initially present. Modifications for ASD/ neurodevelopmental presentations with respect to therapies like CBT : Service users with comorbid ASD and Personality Disorder need adjustments of the standard intervention protocols we use. We are recruiting to one specialist post to provide for people with these comorbidities in South and West Norfolk, and we have set up a working group in psychology to guide us as to evidence and Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH Web: www.nsft.nhs.uk - 3 - best practice in relation to modifying our therapeutic offer. This comorbidity will be recognised as an area of increased focus within our revised PD/CEN strategy. I hope that this information offers you reassurance on the areas raised. Yours sincerely Deputy Chief Executive & Chief People Officer Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH Web: www.nsft.nhs.uk
See every Prevention of Future Deaths report matching Norfolk and Suffolk NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.