Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0145, written 29 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 | 29 Apr 2019 |
|---|---|
| Reference | 2019-0145 |
| Deceased | David Price |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication 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 | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | THIS REPORT !S BEING SENT TO: Chief Executive of Stockport Clinical Commissioning Group 4 [CORONER - | am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 13" November 2018, | commenced an investigation into the death of David Alan Price The investigation concluded on the 24" April 2019 and the conclusion was one of Alcohol-Related Death. 4 | CIRCUMSTANCES OF THE DEATH David Alan Price had a long history of using alcohol to cope with his mental health. He had successfully completed detoxification programmes in the past with subsequent relapses. He had accessed mental health services but with limited success. On 12'* November 2018 he was found at his home address Post-mortem toxicology found a fatal blood alcohol reading of 509 mg%. There were no suspicious circumstances or third party involvement in his death. [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 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. — } The inquest heard evidence that David Alan Price had a long standing problem with alcohol which he used to self-medicate his anxiety in particular. He made a number of attempts to give up alcohol. These were ultimately unsuccessful. The inquest heard that one of the challenges was to provide support which would enable him to treat his mental health difficulties e.g. anxiety alongside detoxification and supporting him in staying alcohol free. The inquest heard that he would have benefited from an integrated mental health counselling/detoxification service. This would have enabled joint treatment. Such a programme is not available in Stockport. 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by 24" June 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. COPIES and PUBLICATION ! have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely an Price's wife, who may find it useful or of interest. | 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. Alison Mutch OBE HM Senior Coroner 29.04.2019 N
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.
NHS Stockport Clinical Commissioning Group 4th Floor Stopford House Piccadilly Stockport SK1 3XE Tel: 0161 426 9900 www.stockportecg.nhs.uk 24" June 2019 Alison Mutch HM Senior Coroner Coroners Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Re: Response to Regulation 28 Letter: David Alan Price | write following the inquest of David Alan Price heard on 13" November 2018 and concluded on 24" April 2019. The concerns you have raised after hearing the evidence have been brought to my attention, the purpose therefore of this letter is to respond to the action you raised following the sad death of Mr Price. Your letter states that Mr Price would have benefited from an integrated mental health counselling/detoxification service, which would have enabled joint treatment, and you have asked the CCG to take or propose actions to address your concerns. In developing the actions to respond to your concerns the CCG has discussed the provision of support with both the Local Authority Public Health Department who are responsible for commissioning alcohol and substance misuse services and Pennine Care NHS Foundation Trust who provide local mental health services. 1 would like to set out the provision that is in place to address the needs of clients like Mr Price who present with both alcohol and underlying mental health problems. e Pennine Care NHS Foundation Trust provide specialist alcohol treatment service, which includes community detoxification within a structured treatment programme. The treatment programme is provided by trained alcohol workers who are competent in addressing underlying common mental health problems, such as anxiety and depression ¢ Self Help Services (The Big Life Group) supports people to access an eTherapy/online computerised treatment programme for substance misuse which allows people to resolve psychological and lifestyle issues associated with alcohol or substance misuse. Seif Help services also provide one to one psychological support for people with common mental health problems. We know through activity reporting and monitoring that uptake of this service offer could be improved and having identified that uptake of this service needs to be improved Self Help Services will continue to promote the offer with Alcohol service providers. ¢ Healthy Minds (Pennine Care NHS Foundation Trust) employ a therapist within IAPT (Improving Access for Psychological Therapies), who work with people with alcohol issues, * The Liaison Mental Health Team (formerly RAID) employ Alcohol Workers who provide follow-up appointments and support in the community for those who frequently present to the Emergency Department. We recognise that with these services in place Mr Price should have been able to benefit from them, but did not. The CCG and Local Authority have reviewed and are recommending the following actions: 1. Continued and ongoing promotion of services to support people with alcohol and other substance misuse problems experiencing mental health problems. Both CCG and Local Authority Public Health Department, through routine contract meetings will request regular updates on service promotions and communication between mental health and alcohol and substance misuse services 2. Monitoring access, activity and outcomes for people with alcohol issues accessing mental health/psychological therapy services, through regular contract meetings. We believe that the actions set out in this response provide assurance that services are in place in Stockport to meet the needs of people with both underlying mental health and alcohol problems. If you require any further information do not hesitate to contact me. Yours sincerely interim Accountable Officer
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