Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0203, written 20 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jun 2019 |
|---|---|
| Reference | 2019-0203 |
| Deceased | Michael Cox |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Care Home Health related deaths · 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 Michael John Owen COX, deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Strategic Commissioner (Children’s, Families and Adults) Cornwall Council CORONER | am Andrew Cox, Acting Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 08/09/2017, an inquest was opened into the death of Michael John Owen Cox who died at Ridgewood Care Home, in Cornwall on 01/04/2017. The inquest concluded, after a four-day hearing before a jury, on 13/06/2019. The jury recorded a conclusion of misadventure due to drug/alcohol use. CIRCUMSTANCES OF THE DEATH Michael had a long history of mental illness. He had previously been diagnosed with paranoid schizophrenia and had been detained under section 3 of the Mental Health Act. This had been suspended and a Community Treatment Order was in place. For a number of years, Michael had lived at a specialist facility in Wales. In 2016, the therapeutic relationship broke down and Michael was recalled to Fletcher Ward at Bodmin hospital. There were concerns about his drinking and he agreed to enter a detoxification programme. His consumption of alcohol, however, did not appear to affect his mental health and at the time of his recall he was not acutely unwell. As he was not acutely unwell, it was recognised that the hospital ward was not an appropriate venue for him to live. Attempts were made to find a placement for him in the east of the county but these were unsuccessful. Michael's history of threatening violence to others and being involved in assaults together with previous episodes where he set fire to property and himself is likely to have been a factor in the number of placements that were potentially available. A placement was found for Michael at Ridgewood care home in Camborne. He moved there in July 2016. The home had a zero tolerance policy to alcohol. In March 2017, it became apparent that Michael had been drinking secretly and it seems likely (although there is no evidence of this) that this had been on-going for some time. There had been no witnessed deterioration in his mental health or mood. The situation was discussed with the Responsible Clinician and others. As there had been no deterioration in his mental health, there was no basis in law for recalling Michael to the acute ward. The care home, however, did not have staff with qualifications or experience in dealing with clients who had addiction or substance misuse issues. Michael was found deceased in his room on the morning of 01/04/2017. 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 potential shortage of suitable placements for individuals with a mental health history similar to Michael. Evidence was heard at the inquest that when such individuals are placed at a suitable facility, it can become their home and they may live there for years and even decades. Accordingly, spare places can be at a premium. Evidence was also heard that social workers (and in this case an occupational therapist) have persistent difficulties in finding suitable placements suggesting that resources are limited. 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. | would be grateful if you would consider, in light of this death, whether there is an adequate stock of available accommodation for individuals who present with the challenges apparent in someone like Michael. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16” August 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 family, Ridgewood care home and the Community Mental Health Team. | have also sent it tol at Cornwall Council 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. [DATE] [SIGNED.BY CORONER] 20/06/2019 C -— = ™~
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.
Information Classification: CONTROLLED Mr Andrew J. Cox Acting Senior Coroner for Cornwall and the Isles of Scilly Cornwall Council Your ref: AJC/LJB By email only: cornwallcoroner@cornwall.gov.uk Date: 21 August 2019 Dear Mr Andrew Cox Response to Regulation 28 Report to Prevent Future Deaths – Michael John Owen Cox I am writing in response to the letter and above-named report (received 20 June 2019) following the inquest into the death of Mr Michael Cox. Your report highlights some of the specific issues that are presented when people with complex needs (often relating to drug and alcohol use, and issues of mental ill health) move from bespoke assessment/treatment services and into mainstream and longer-term placements. Michael Cox’s case demonstrates that there is a real need for more and better accommodation-based services featuring care and support that is capable of meeting needs such as his. Much work is presently happening in Cornwall in recognition of the fact that existing service provision does not always meet the needs of the most complex individuals in the county. Below, I have listed some of the contemporary initiatives that are underway to address this shortfall. I hope that you will appreciate the effort that is being made to ensure that in future, people will benefit from the services that they need, staffed by people with the skills and capacity necessary to cater for them. Strategic work – identifying and recognising the issues. The Cornwall Community Safety Partnership has developed a draft multiagency Cornwall Complex Needs Strategy (2019-23) to improve the approach to partnership working and provision in Cornwall, including for people with complex needs related to mental health and drugs/alcohol. The strategy includes recommendations to develop a more coordinated multiagency approach to support this group of people, and a system of accommodation provision with access to care and support that meets the needs of those at different stages of recovery. The draft multiagency Cornwall and Isles of Scilly Adult Mental Health Strategy (2019-24) also identifies the need to improve access to specialist support for those with a dual diagnosis of both mental health and drug/alcohol problems. It highlights the need to improve the pathway for people to receive a social care assessment and to access appropriate care and individualised support, and commits to exploring future opportunities to develop appropriate accommodation to meet the needs of those with complex and enduring mental health conditions. The national Making Every Adult Matter (MEAM) approach helps local areas to design and deliver better coordinated services for people experiencing multiple disadvantage. Cornwall has been Cornwall Council | Konsel Kernow County Hall, Treyew Road, Truro, TR1 3AY E: helen.charlesworth-may@cornwall.gov.uk | T: 01726 226927 www.cornwall.gov.uk Information Classification: CONTROLLED selected as a MEAM pilot area, and strategic and operational partners are currently working together to agree and develop the most appropriate method of delivering MEAM in the county. Case studies have recently been reviewed, and it has been determined that people with issues of mental ill health, drug/alcohol issues, people displaying aggressive/violent behaviour, schedule one offenders, people with convictions for arson, and people who have had multiple previous evictions are key cohorts that the system is currently failing to properly support. System redesign – addressing the issues. For the assessment and care management phases, a multiagency operational dual diagnosis steering group was formed in November 2018. The group is focused on strengthening the interface between secondary and tertiary mental health and drug/alcohol services, and identifying barriers that prevent multiagency joint working. This work is intended to ensure that no individual (including those in residential care and accessing care and support in the community) is excluded from any service, and to improve the referral pathway between mental health (such as Community Mental Health Teams) and drug/alcohol services (such as Addaction). For the delivery of services and support, a complex needs system model has been proposed, which will be implemented by the Cornwall MEAM Strategic Board. The model includes the expectation that multi-disciplinary team meetings take place where people have multiple needs, that a lead professional is identified to ensure that the person is linked to all appropriate support, that creative solutions are considered including links to community assets, and that there is a clear escalation route for any cases where appropriate support and/or accommodation has not been identified. Social care and accommodation with care. A strategic task and finish project including Adult Social Care (ASC), NHS Kernow Clinical Commissioning Group (NHSK), Cornwall Partnership NHS Foundation Trust (CPFT), Housing Strategy and Partnerships, and the Drug and Alcohol Action Team, as well as other partners, is currently being established to take forward recommendations in relation to social care and accommodation to ensure that the available provision is meeting people’s needs. This task and finish project runs until April 2021, during which time it will work on the following. Prevention - review and recommission of the ASC and NHSK jointly-funded and externally- commissioned prevention services that provide support for people in relation to preventing crisis, self-management of health and wellbeing, and increasing independent living skills. Domiciliary care – review of the needs of people assessed as eligible for social care related to mental health and/or drugs/alcohol and the approach to commissioning domiciliary care for this client group by ASC and CPFT. Supported housing - work with providers of housing in Cornwall in order to understand the needs, availability and gaps in supported housing provision for people with mental health/complex needs in Cornwall. A clear strategic approach will be agreed by the task and finish group regarding the development of specialist supported housing for people with mental health and/or complex needs in Cornwall. The project will include analysis of demand and supply, and a profile on the housing requirements, Information Classification: CONTROLLED including required locations and types of accommodation. A review will take place regarding the current residential/nursing care home and supported living provision to better understand the gaps and shape the market to meet needs. The work required to shape the market following this is expected to go on beyond April 2021. (Timescales for this are to be confirmed). I hope this letter reassures you that the gaps in current service provision have been identified, and that work is planned to ensure that people with mental health and other complex needs in Cornwall receive access to appropriate accommodation with care and support. Please let me know if you have any questions or if further information is required. Yours sincerely Strategic Director, Adult Social Care & Health Adult Social Care Tel: Email:
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