Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0313, written 24 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 | 24 Sep 2019 |
|---|---|
| Reference | 2019-0313 |
| Deceased | Rebecca Marshall |
| Coroner | Briony Ballard |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| 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 1S BEING SENT TO: The Chief Executive of Kent and Medway NHS and Social Care Partnership Trust CORONER tam Briony Ballard, Assistant Coroner, for the coroner area of Inner London South CORONER'S LEGAL POWERS t 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 30 November 2017 this jurisdiction commenced an investigation into the death of Rebecca Marshall. The investigation concluded at the end of the inquest on 27 August 2019. The conclusion of the inquest was that Miss Marshall died as a result of suicide. CIRCUMSTANCES OF THE DEATH In March 2017, Miss Marshall whose home address was within the Kent area was referred for an mental health assessment in Maidstone, Kent to manage her escalating self-harm, depression, anxiety and angry outbursts. Despite the subsequent primary mental health assessment identifying the need for a full diagnostic secondary mental health assessment and despite two periods of crisis at the end of July 2017 and the beginning of September 2017, no such assessment was forthcoming. in about October 2017, Miss Marshall started her university degree at Goldsmiths University, London and accordingly began residing in university halls of residence. She had a further period of crisis and saw a local London based GP who referred her to the community mental health team under the South London and Maudsley NHS Foundation Trust (SLaM). At the same time she sought to and was accepted onto the University's counselling service. The assessment by secondary services from Kent Medway NHS and Social Care Partnership Trust (KMPT) which had been requested much earlier in the year eventually did take place in November 2017. However, this was only a routine medication review at which it was concluded because Miss Marshall was reporting she was under a London based GP and community mental health care team there was no need for any further input and she was discharged to the care of her London based GP. There was no interagency communication between staff employed by KMPT and / or SLaM. Despite urgent referrals being made when ihere was a further deterioration later in November 2017 no senior review was arranged. Miss Marshall was discovered deceased in her room on 27 November 2017 after the alarm was raised by her father. 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. SE ST The MATTERS OF CONGERN are as follows. — (1) At inquest | was told that both Trusts involved: SLaM and KMPT had investigated the circumstances of Miss Marshall’s death independently. (2) At a pre-inquest review hearing on 18 October 2018 1 suggested that in light of the circumstances of the case it would be preferable for a joint report to be produced focussing on the apparent lack of interagency communication which had apparently led to Miss Marshall not being reviewed as required. (3) At inquest | was told that following the pre-inquest review hearing there had been a meeting between the two Trust's and that the report from KMPT would be exhibited to and form part of the report of SLaM Trust. (4) Both reports identified a number of missed opportunities in Miss Marshall’s care, including steps to ensure joint ownership of her care when she became a student in London. (5) | was told at inquest of the lessons learnt by both Trusts and the actions completed. (6) From what | was told at inquest however, it appeared that KMPT had not taken any steps to address the issues of obtaining collateral information from or sharing information with other Trusts involved in the care of one of their patients, particularly if they have moved, permanently or temporarily to / from KMPTs area, (7) Miss Marshall formed part of what could be considered to be a particularly vulnerable group of individuals, namely a member of the student population suffering from mental health challenges whose continuity of care could not be guaranteed by good inter Trust communication. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 13 November 2019. |, the corener, 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 | the de ‘s father, SLaM NHS Foundation Trust, HE MN within KMPT, an Speciality Doctor. 1am 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. 24 September 2019 Frcmng Ballard [DATE] [SIGNED BY CORONER] w
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.
Kent and Medway | NHS and Social Care Partnership Trust Chief Executive's Office Trust Headquarters Farm Villa Hermitage Lane Maidstone Kent ME‘16 9PH CONFIDENTIAL Assistant Coroner Miss Briony Ballard Coroner for Inner South District Greater London Southwark Coroner's Court, 1 Tennis Street, Southwark, London SE1 1YD 7 November 2019 Dear Miss Ballard Response to Prevent Future Deaths Report for Rebecca Marshall (deceased) a | write as requested following receipt of your Prevent Future Deaths Report of 25th September 2019. . | have shared your report with my team and other key colleagues, and we have, as you would expect, carefully considered the concerns you raised. As a partnership organisation, we are committed to effective inter-trust and inter-agency working and | am deeply sorry that was not the impression of us that you were left with in this extremely sad case. Rebecca’s suicide was a tragedy, and | want to record here, my commitment as Chief Executive along with that of my team, to ensuring that where things need to be improved as a result of learning from what happened to Rebecca, the required changes are both made and sustained. Matters of Concern Your report identified two specific concerns where you considered KMPT had not taken steps to address areas of risk; a) The risk that occurs at the point in time when a patient moves permanently or temporarily (such as going to University as in Rebecca’s case) from one geographical area to another. b) The innate vulnerability of students who are suffering mental health challenges and the need to ensure at the point of transfer of care there was effective inter-agency communication between trusts to ensure continuity of care of the patient. Chairman — Julie Nerney Chief Executive — Helen Greatorex Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, Kent, ME16 9PH_ Tel: 01622 724100 Page 1 of 3 : i We fully accept the concerns raised, and agree entirely that anyone who moves in to or out of our area should be confident that we will (with their agreement) seek and share relevant information about their care needs and history in order to ensure their safe transfer. Our Transfer and Discharge of Care policy is designed to achieve exactly that by ensuring that Care Coordinators are clear about their responsibilities in such situations and prompted to contact other areas for background information. We expect all staff to adhere to this policy and ensure that information is sought and provided from other relevant organisations at the point of a care transfer. We recognise that the transition to university can be a very anxiety provoking time for young adults. We recognise too that there is a need to work closely, not only with the corresponding mental health trust, but with the relevant university. Actions Taken e The Transfer and Discharge of Care policy has been reviewed to ensure that it properly addresses any and all instances of care transfer, including vulnerable populations. This includes students, traveilers and refugees. e A programme of reminders and sharing of the Transfer and Discharge of Care policy is in place across the Trust, underpinned by sharing the learning about the gaps in Rebecca’s care and what should have happened. e Development (in partnership with our local universities) of a shared care protocol between KMPT and Higher Education to ensure clear and easy two way communication to further strengthen the safeguards for students’ mental health. e Development of a fast track referral route from the Universities to our Community Mental Health Team. e Piloting of a new, direct referral form from the University Health Centre. e Strengthening of our Consent to Share Information process which now ensures that we are given permission by students to share information with the University Health Centre. e We have liaised with South London and the Maudsley and are incorporating their Transient People policy in to our overarching document You have my personal assurance as Chief Executive, that we will continue to test and refine our processes, sharing our reflection and learning from Rebecca’s story with staff who deliver front line care every day. At the next meeting (22" November 2019) with the Kent Universities as part of this review we will seek input from our University partners on the process of engagement and joint working when Kent residents attend university out of County. Yours sincerely Helen Greatorex Chairman — Julie Nerney Chief Executive — Helen Greatorex Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, Kent, ME16 9PH Tel 01622 724100 Page 2 of 3 : i i i i
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