Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0261, written 27 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Aug 2019 |
|---|---|
| Reference | 2019-0261 |
| Deceased | Kim Morris |
| Coroner | Lydia Brown |
| Coroner area | Leicester City and Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Leicestershire Partnership NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dr P. Miller, Chief Executive, Leicester Partnership NHS Trust. 1 CORONER am Lydia Brown, Assistant Coroner, for the area of Leicester City and Leicestershire South 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 24 September 2018 I commenced an investigation into the death of Kim Morris The Inquest concluded on 26~h July 2019 Cause of death: 1 a Hypoxic brain injury 1 b Hanging —suspension by ligature 4 CIRCUMSTANCES OF THE DEATH Kim died from the consequences of suspension by ligature; losing her life in the Leicester Royal Infirmary on 22nd September 2018 having been found in the garage at home and resuscitated on 20th September 2018. Coroners Conclusion: Kim had been receiving treatment for her mental ill health for many years in primary care and only occasionally in secondary care until she went into crisis during 2018. Admission to the local crisis house was prematurely terminate due to the in- appropriate admission of another patient whose interactions with Kim made her feel unsafe and she therefore lost a positive therapeutic opportunity not only on that occasion but on future occasions as well. She felt unable to engage fully with the crisis team due to a significant lack of continuity of care and this impacted on her negatively. She took her own life the day after that treatment concluded, but her intention at that time was unclear. 5 CORONER'S CONCERNS Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris, It was accepted that she should be referred to a Community s chiatric nurse to continue her en a ement and this ma brin some continuit of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team. The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust's "at risk" register. There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team. My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved. 6 ACTION SHOULD BE TAKEN I n my opinion action should be taken to prevent future deaths and I believe you 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 22~d October 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, have sent a copy of my report to the Chief Coroner and to the following Interested Persons. (Partner) is (Brother) (Brother) Mr J. Adler, Chief Executive, University Hospitals of Leicester NHS Trust. Sir David Behan, Chief Executive, Care Quality Commission. 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 a useful or of interest. You may make re your response, about the rele e o e publication of your response by the Chief Cor erson who he believes may find it entations to me, the coroner, at the time of r. 9 [DATE [SIGNED BY CORONER] 27tH Aug 019
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.
A university teaching and research-active Trust
Bridge Park Plaza
Bridge Park Road
Thurmaston
Leicester
LE4 8PQ
Tel: 0116 295 1350
www.leicspart.nhs.uk
Direct dial:
Email: fra
Our Ref: KM/REG28/
15 October 2019
By email to Leicester.coroner@leicester.gov.uk
Lydia Brown
Assistant Coroner
Leicester City and South Leicestershire
The Town Hall
Town Hall Square
Leicester LE1 9BG
Dear Mrs Brown
Re: Kim Beverley Morris
Further to your report dated 28 August 2019, in accordance with paragraph 7,
Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013, I offer the following response.
We have investigated the matters of concern that have arisen during the course of
the inquest of Mrs Kim Beverley Morris. Leicestershire Partnership NHS Trust takes
these matters very seriously and I hope that you and Mrs Morris’s family will be
satisfied that we have taken the appropriate measures to prevent such an
occurrence happening again.
The matters of concern you have raised are as follows:
The Crisis team is not offering a service that is suitable to support such high risk
individuals as Mrs Morris and that the expectations of service users are low due to
the high and unrelenting pressures and demands on the individuals trying to provide
care.
Service Response
We acknowledge your concerns that we are not able to offer a service to support
such high risk individuals, and would like to reassure you that, as a Trust we take
these concerns seriously. We have received additional investment to further
enhance the Crisis Service, to enable us to improve the service we deliver.
Our additional investment of £962k will further enhance the staffing in the Crisis
Service by recruiting 8.5 whole time equivalent registered staff and 12.6 whole time
Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ
Chair: Cathy Ellis Chief Executive: Angela Hillery
We are a smoke-free Trust.
NHS organisations now use 100 per cent recycled paper as part of our sustainability commitment
View our privacy notice at www.leicspart.nhs.uk/_Aboutus-Whatwedowithyourinformationprivacynotice.aspx
equivalent unregistered staff. These additional staff will increase the capacity of the
team, and alleviate some of the known high demand and pressures. A full time
Psychologist is also being recruited to support psychological interventions and will
provide supervision and support to staff in the team. We are expecting that this
additional support will be fully in place by the end February 2020.
The concerns specifically related too:
1. There were numerous visits and telephone encounters with many different
individuals and the role of the key worker did not reduce these.
Service response
We are reviewing the Standard Operating Procedure (SOP) for the Keyworker role,
and their responsibilities within the Crisis team. This review will ensure that we
clearly define the expectations for the Keyworker role for Registered Nurses, Mental
Health Practitioners and Health Care Support Workers employed in the team. The
SOP will confirm the responsibilities for assessment, ongoing care planning,
monitoring of service users and discharge planning. Clear information about the role
of the Keyworker will be available to patients, families and carers by the end of
November 2019.
2. It was accepted that Mrs Morris be referred to a Community Psychiatric Nurse
to continue her engagement and continuity of care prior to discharge, but no
contact was made prior to her discharge, potentially leaving her fearful of a
delay.
Service response
The discharge process for patients under the care of the Crisis team to Community
Mental Health Team (CMHT) is being reviewed to ensure that there is an agreed and
documented referral process with a prioritisation rationale for the patient to be
immediately allocated to a CMHT team member. The Crisis team will retain
responsibility for the patient until an appointment with the CMHT team member has
been offered. The Crisis team will work with the CMHT to ensure that the crisis and
contingency plan is updated. Our Matron for Crisis Services will have responsibility
for ensuring that ongoing monitoring is in place to ensure compliance is adhered to.
This new process will be fully in place by the end of December 2019.
3. The Court was told that due to the team set up, continuity of visits was not
possible and that the demands on the team significantly outweigh the
resources available.
Service response
We accept our continuity of care is challenged and want to assure you we are
committed to improve this area of care with the new investment outlined above. We
have already implemented new ways of allocating registered clinicians for
assessments to increase the time available to deliver treatment. Registered staff
members are now rostered four weeks of carrying out assessments only. Outside of
these blocks they will then focus on treatment. This process was implemented in
Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ
Chair: Cathy Ellis Chief Executive: Angela Hillery
We are a smoke-free Trust.
NHS organisations now use 100 per cent recycled paper as part of our sustainability commitment
View our privacy notice at www.leicspart.nhs.uk/_Aboutus-Whatwedowithyourinformationprivacynotice.aspx
June 2019 and the team are currently monitoring the impact this has on continuity of
care.
In addition our new resources and new posts associated with this will result in an
increase in daily packages of care we are able to offer. We will be completing an
audit reviewing patients open to Crisis Services between September 2018 and
September 2019 to establish the band of staff, and the number of visits they have
completed for patients open during this timeframe. This will be completed by end of
November 2019 and will allow us to have a clear understanding of the current
continuity of care delivered by the Crisis team, and enable us to develop an
improvement plan in this area.
We are also reviewing the NHS National Benchmarking data and are committed to
working with other Trusts to ensure best practice within our Crisis Service.
4. Mrs Morris suffered distress at having to tell her story repeatedly to new
workers.
Service response
The additional investment will support our commitment to improving the continuity of
care of all patients in Crisis we support. This includes the review of our local
guidance for staff on pre-visit preparation, which expects all staff to read the previous
visit entry, review any recent risk assessments, confirm outstanding actions from the
previous visit have been completed, and check any communication needs prior to
the scheduled visit. We will develop a spot check tool to establish that the changes
as the result of the review of the local guidance have been embedded into practice.
We will ensure that we are able to offer assurances of our compliance on this
through co-producing a spot check tool directly with our service users.
As a Service we are all committed to ensuring that all the identified service actions
are robust and completed within the agreed timescales. We hope this reassures you
that we are taking appropriate action in response to your findings.
If I can be of any further assistance to you please do not hesitate to contact me.
Yours sincerely
Angela Hillery
Chief Executive
Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ
Chair: Cathy Ellis Chief Executive: Angela Hillery
We are a smoke-free Trust.
NHS organisations now use 100 per cent recycled paper as part of our sustainability commitment
View our privacy notice at www.leicspart.nhs.uk/_Aboutus-Whatwedowithyourinformationprivacynotice.aspx
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