Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0257, written 29 Jul 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 Jul 2019 |
|---|---|
| Reference | 2019-0257 |
| Deceased | Alistair McDonald |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| Category | Suicide (from 2015) |
| Organisation named | Herefordshire and Worcestershire Health and Care NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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NHS) Worcestershire Health and Care NHS Trust Chief Executives Office 27 September 2019 Worcestershire Health and Care NHS Trust 2 Kings Court Charles Hastings Way HM Coroners Office - Manchester City Area Worcester Exchange Floor WRS5 1JR The Royal Exchange Building Cross Street Tel: 01905 681667 Manchester ; M2 7EF | By email and post www.hacw.nhs.uk Dear Sirs, Re: Regulation 28: Report to Prevent Future Deaths in respect of Mr Alastair McDonald | am writing in response to your report to prevent future deaths dated 29 July 2019 addressed to Dr John Devapriam, Medical Director of the Trust. | believe that some of the concerns that you expressed in your report may have been allayed had the Trust been invited to adduce oral evidence at the Inquest to expand on the information before you. | am grateful for the opportunity of responding to your concerns. The Trust is always keen to learn from any tragic incident and | hope that this response satisfies you that we have reviewed the issues raised appropriately. | have addressed the eight points that you have raised: 1. Review the self-harm and suicidal ideation criteria The referral criteria sent to support the statement written »p 2; developed in 2015 and was in place at the time of the referral made to the Child and Adolescent Mental Health Single Point of Access (CAMHS SPA) in January 2016. Action: We are at present reviewing our CAMHS SPA and the workforce supporting the delivery of the service. This will support the consistent application of clinical referral principles which will consider the severity, risk and impact on the individual in line with their presenting mental illness/disorder or emotional health and wellbeing. This process will be completed by March 2020. The lack of a specific plan for referrals to other services which proved unsuccessful The CAMHS SPA triaged the initial referral received on the 19" January 2016 and considered all the information contained within the referral. The outcome of the triage was that it was considered most appropriate that the first line of treatment was through a Cognitive Behavioural Therapy (CBT) approach which was able to be achieved through engagement with Healthy Minds. Healthy Minds is a service which supports people, aged 16 and over, who are experiencing problems such as stress, anxiety, low mood and depression. It is a free, confidential service offering a range of talking therapies and support including short courses, online therapies, and guided self- help. The outcome of the referral was sent to both the GP and Mr Alastair McDonald. At this point the referral to CAMHS was closed. The second referral to CAMHS SPA following a telephone discussion with the GP resulted in a Choice Assessment which was attended with his mother. Again the outcome of this was the recommendation that Mr Alastair McDonald engage with the Healthy Minds service. Action: We recognise that we should have included the telephone number so that Mr Alastair McDonald could access Healthy Minds. The requirement for CAMHS SPA to include information and contact details of all agencies to whom they signpost on to was included in September 2018. 3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist The staff working within the CAMHS SPA are experienced mental health practitioners from a wide range of professional backgrounds. These clinicians receive a robust induction, regular clinical and managerial supervision along with ongoing training to ensure consistent high quality care delivery. There are also established pathways for seeking support and supervision if clinically indicated to support decision making which include managerial or psychiatry support. In line with national guidance the difficulties described are most effectively addressed with a stepped model approach with a CBT approach as a first line intervention to manage the anxiety he described, and as explained Healthy Minds are an appropriate service to deliver this. Since 2017 the service has introduced a process whereby all Choice assessments are reviewed in the weekly Multidisciplinary Team Meeting (MDT). This meeting is attended by all the disciplines working within the service which includes nurses, psychologists, psychotherapists and psychiatrists, This provides a forum for case discussion with a shared outcome decision. We are satisfied that the systems and processes in place since 2017 address the whole position and psychiatry concern. We are satisfied that the clinician who assessed Mr McDonald was appropriately experienced and qualified to undertake the assessment. 4, Ensuring a proper line of communication with the patient and the patients family to ensure appropriate reviews if the patients mental state deteriorates The Choice assessment was attended by the mother of Mr Alastair McDonald, and the detailed assessment notes that her views were taken into consideration in line with the overall formulation of the assessment and outcome. The outcome of the assessment was that Healthy Minds service was considered appropriate. Alongside this advice health advice was provided on abstaining from alcohol (which was agreed with his mother) along with being provided with the contact number for the Samaritans which could be used as a point of contact if needed. Sadly, we can find no evidence that Mr McDonald contacted the Healthy Minds service. The assessment also recorded that Mr McDonald was in contact with his Relate counsellor and had a forthcoming appointment. Our view is that both Mr McDonald and his family knew (as they had done in March 2016) that if they felt that there was a deterioration in his mental state then they could return to the GP who could refer back to services. Upon review of this case the actions taken are considered to be reasonable and proportionate to Mr Alastair McDonald’s presentation during assessment and therefore no actions are identified. Chairman: Chris Burdon Chief Executive: Sarah Dugan Working together for outstanding care 5. Obtaining detailed feedback from the services the patient is referred to, to check on attendance and progress The Worcestershire CAMHS Service has reviewed as to if it is realistic and achievable to follow up and obtain detailed feedback from each service that a patient is referred to. The Service is not commissioned to do this and it is the role of the GP to be the initial point of contact for a person and to refer to more specialist services as required. On average the CAMHS SPA service receives 210 referrals a month. Alongside this we have approximately 1500 children under the care of CAMHS. Patients are encouraged to adopt an autonomous approach with respect to their healthcare, seeking referrals to services as and when appropriate. Specific provisions apply to patients who do not have capacity to make such decisions themselves or require compulsory treatment under the Mental Health Act; neither of these scenarios applied to Mr McDonald. It would not be considered realistic, or in our view, an appropriate use of resources, to signpost a patient and then seek detailed feedback. 6. Recognising that some patients will only make partial disclosure of their true symptomology and history As previously stated the staff working within the CAMHS SPA are experienced mental health practitioners from a wide range of professional backgrounds, with extensive support and supervision arrangements in place. It is not unusual for patients to not fully disclose the extent of their symptomology. Clinicians are skilled in assessing patients holistically, through a range of mechanisms. The detailed assessment notes disclosure (alcohol use; previous suicidal thoughts; relationships and friends) to the CAMHS practitioner which was not detailed elsewhere. This suggests that there was a therapeutic trust relationship and that these issues were taken into account when the assessment was concluded. Alongside this there was evidence of engagement with Mr Alastair McDonald’s mother, as well as recognition that he was already receiving counselling via Relate. Upon review of this case the actions taken are considered to be reasonable and proportionate to Mr Alastair McDonald's presentation during assessment and therefore no actions are identified. 7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this The triage and assessment process involved seeking feedback from the GP; Mr Alistair McDonald and his mother. His existing support structures were also considered which included his engagement with Relate. The detailed assessment noted that Mr Alistair McDonald wanted to recover, describing that he felt something inside that wants him to get better. He described mood swings and recognised that his mood would fluctuate in response to events, but that he was talking about his issues and looking at a brighter future. Chairman: Chris Burdon Chief Executive: Sarah Dugan Working together for outstanding care He denied any active suicidal ideation and advised that he had made promises to people not to harm himself. He described being active in seeking help and was being more open with his family about how he was feeling. He acknowledged that he had self-harmed in the past, but that it didn’t help and he wouldn't do this again. The use of alcohol and the impact of this was discussed, along with the actions which positively impacted on his mental state. The clinical documentation has been reviewed and was felt to be appropriate and reasonable as well as the outcome decision to recommend contact with the Healthy Minds service. Any assessment is relevant at a point in time, an individual’s presentation may fluctuate dependant on various extraneous factors. | note that Mr McDonald tragically died 2 years after this assessment. 8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this Following the Choice assessment undertaken on the 12" April 2016 Mr Alastair McDonald was discharged with CAMHS following having received signposting information of alternate services. A summary of the assessment and the outcome was detailed in a letter which was sent to both Mr Alastair McDonald and his GP. We note in the detailed assessment that the assessing practitioner attempted to telephone Mr Alastair McDonald on the 26" April 2016, The assessment notes however that the contact number we had on the system was not recognised. Follow up telephone contact would not be expected as following the assessment and the outcome, which in this case was signposting, Mr McDonald was discharged from CAMHS. In 2019 we implemented systems with our CAMHS SPA and CAMHS reception staff whereby we take opportunity to confirm contact details at every opportunity. Conclusion | would like to thank you for drawing this matter to my attention, | confirm that the points that you have raised have been carefully considered and the responses set out above. | confirm that subject to redaction of the patient's name, | would not have any representations to make in respect of publication of this response. If you have any further queries do not hesitate to contact me. Yours faithfully Sarah Dugan Chief Executive Chairman: Chris Burdon Chief Executive: Sarah Dugan Working together for outstanding care
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS This report is made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Recipients This report is being sent to" e Dr John Devapriam - Medical Director, Worcestershire Health and Care NHS Trust Coroner lam Nigel Meadows, HM Senior Coroner for the Manchester City Area 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 22 May 2018 | commenced an investigation into the death of Alistair Patrick McDonald, aged 19 The investigation concluded at the end of the inquest on 5 June 2019. The cause of death was found to be: ja Hanging The conclusion of the inquest was Suicide. Circumstances of death The deceased was born on 17 February 1999 and lived in Malvern, Worcestershire with his parents, together with his two brothers He did not suffer any significant physical health condition or illnesses He was a high achiever academically When he was about 16 years old his mother learned from his then girlfriend that he was expressing very disturbing thoughts His outlook on life and his future seemed very troubled On becoming aware of this, his school suggested that he might consult the ‘Relate Counselling Service’, but he did not find this helpful and so with the assistance of his parents, he consulted his GP, who was anxious to make an urgent referral to the local CAMHS He disclosed he was experiencing suicidal ideation, which he repeated when seeing his GP practice in March 2016. The initial referral by his GP was made on 19 January 2016 and he did have a history of inflicting deliberate self-harm The result of this CAMHS referral was that he could be supported by the ‘Healthy Minds Service’ A second GP referral was made due to the disclosed specific suicidal intent He was assessed on 12 April 2016 and confirmed his suicidal thoughts, but it did not appear that the wider perspective of a young man who had just turned 17 readily admitting to suicidal ideation, despite his superficial presentation, was recognised as unusual and disturbing It was suggested that he should consider CBT for his anxiety via the Healthy Minds Service, but it was felt that he did not meet the criteria for CAMHS intervention. He did not apparently have an assessment by a consultant psychiatrist, but what was described as a ‘locum CAMHS senior practitioner’. A letter was written to the deceased on 26 April 2016 indicating that he did not meet the ‘criteria for CAMHS at present’ This acknowledged difficulties in communicating with the deceased and his mother. However, on one interpretation he could have met the criteria set out in a policy document There did not appear to be any clear advice as to what to do should his suicidal feelings persist and that any help he might receive from the Healthy Minds Service was not successful There did not appear to be any recognition that he could present a superficially positive state of mind, whereas in reality if subject to more detailed assessment by a psychiatrist that might not have been the true picture There was never any follow-up to check on his progress In 2017 Alastair came to Manchester to study for a degree in Music Whilst in Manchester, he disclosed to a friend that he was struggling with depression and he was found by his friend on a visit to be actively self-harming He was encouraged to seek help as he was clearly having difficulties of a serious nature in coping with day to day life He did not disclose to his parents his deteriorating state of mental health and he had no point of contact back to CAMHS or other psychiatric services On 14 May 2018 he was found dead, hanging by a ligature secured to a door frame 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 ts taken. In the circumstances It is my statutory duty to report to you. The matters of concern are as follows. 1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted 2. The lack of a specific plan for referrals to other services which proved unsuccessful 3 The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist. 4 Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews If the patient’s mental state deteriorates 5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress 6 Recognising that some patients will only make partial disclosure of their true symptomology and history. 7 Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this 8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to dea! with this. Action should be taken In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. 1 Review the self-harm and suicidal ideation criteria. 2 Deal with the issues raised in paragraphs 2-8 above. Your response You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 September 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 following Interested Persons e The family of the deceased | am also under a duty to send the Chief Coroner a copy of your response. 3 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 N Meadows H.M. Senior Coroner — Manchester City Area 29 July 2019
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