Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0307, written 19 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Sep 2019 |
|---|---|
| Reference | 2019-0307 |
| Deceased | Ian Bromley |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | Pennine Care NHS Foundation Trust |
| 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 THIS REPORT IS BEING SENT TO: Ms Claire Molloy, Chief Executive, Pennine Care NHS Foundation Trust, Trust Headquarters, 225 Old Street, Ashton-under-Lyne, OL6 7SR CORONER tam Chris Morris, Area Coroner for Manchester South. 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/S/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 6" March 2019, Alison Mutch OBE, Senior Coroner for Manchester South opened an inquest into the death of lan Charles Bromley, who was found dead on 18" February 2019, aged 52 years. The investigation concluded at the end of the inquest which | heard on 19" August 2019. At the end of the inquest, ! determined that Mr Bromley died as a consequence of hanging. | recorded a conclusion of Suicide. CIRCUMSTANCES OF THE DEATH Mr Bromley first presented to mental health services in January 2019, experiencing low mood and suicidal thoughts connected with a range of personal difficulties. Following an initial assessment, Mr Bromley was offered an informal admission to hospital, but declined this. Instead, he accepted a referral to the Home Treatment Team as an alternative to inpatient treatment. This continued in the guise of one-to-one sessions with a mental health practitioner, alongside antidepressant medication prescribed by Mr Bromley’s General Practitioner. Mr Bromley was found dead on 18" February 2019 at his gym, having suspended himself by the neck with a ligature. 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. — 1. Despite the fact the Home Treatment Team purports to offer a genuine alternative to hospital treatment, it is a matter of concern that the Team does not currently have access to a dedicated Consultant Psychiatrist specifically allocated to the service; 2. Whilst the action plan which accompanied the Trust’s internal investigation made reference to plans to recruit to such a post, the manager from the service who gave evidence appeared unaware of any substantive recruitment process currently in train, let alone the timescales within which it might reasonably be anticipated the post will be filled; 3. Although interim measures are in place whereby practitioners in the Home Treatment Team can access a psychiatrist on a rota system, the court heard evidence that the operation and effectiveness of these measures is patchy, with much depending on the individual approach of the particular psychiatrist in dealing with queries from this team alongside their existing workload. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 14"* November 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 o i .. behalf of the family. | have sent a copy of my report to Stockport Clinical Commissioning Group and the Care Quality Commission, 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. Dated: 19" September 2019 Signature: Chris Moffis HM Area Coroner, Manchester Sguth.
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 Pennine Care NHS Foundation Trust 43" November 2019 Corporate Services Pennine Care Trust Headquarters 225 Old Street Ashton under Lyne HM Area Coroner Lancashire Mr Christopher Morris. OL67SR HM Coroner's Office Telephone: 0161 716 3000 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris Re: lan Bromley ~ DOD 18" February 2019 | write following the Inquest of lan Bromley heard on the 19'" August 2019. Your concems after hearing all the evidence into the circumstances surrounding the tragic death of lan Bromley have been brought to my attention and | have subsequently reviewed the Regulation 28 letter. | am writing to respond to the below mentioned concerns raised: The lack of access to a dedicated Consultant Psychiatrist allocated to the Home Treatment Team service, recruitment to such a post and interim cover from sector Consultant Psychiatrists The Home Treatment Team national core fidelity model does not mandate that teams should have a full time designated Consultant Psychiatrist but that the team should have access to a medic. How this is achieved differs dependant on how local services are commissioned and provided. Some services operate on a model where consultant work will be divided by function i.e. one for inpatient wards, one for CMHT, one for HTT and other areas work on a sector model where the patient is allocated to a consultant dependant on the postcode in which they reside and will have the same consultant no matter where they are in the pathway. Stockport mental health service operates on a sector consultant basis for the majority of services and so patients who come into the service will be allocated a consultant dependant on the postcode where they reside. The exception to this is where there has been specific additional investment. The Home Treatment Team in Stockport had a part-time Associate Specialist who provided input into the team however this person was on long term sick leave at the time of Mr Bromley's referral and so cover reverted to the sector model with which staff are very familiar. ©B disability Trust Headquarters; 225 Old Street, Ashton-under-Lyne, Lancashire OL6 75R. Tel: 0161 716 3000 ag confident Visit us at wavw penninecare nhs uk COMMITTED There are also additional specialist clinical roles in the team which enhance the medical offer. The Home Treatment Team has an Advanced Practitioner in post whose role is to assess, diagnose, treat, prescribe and make referrals for patients, and who works closely with medical colleagues. She will also review crisis patients in clinic and where clinically indicated support home visits. This has been in place for 7 months. The team manager is also now a qualified prescriber and can review and amend patient's treatment. In addition the Home Treatment Team has acquired additional CCG funding to extend the medical cover to the Home Treatment Team. This was known and already agreed at the point of the inquest. In the short term the Trust Medical Director is providing part-time cover to the team. | hope that the information provided offers assurances that the findings of your investigations were already in progress and are a focus of our continuing commitment to improving mental health services in Stockport. Please do not hesitate to contact me should you require any further information. Yours sincerely 7 A Dr Henry Ticehurst Medical Director/Deputy Chief Executive
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