Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0425, written 16 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2019 |
|---|---|
| Reference | 2019-0425 |
| Deceased | Layla Dobson |
| Coroner | John Hobson |
| Coroner area | West Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | Leeds and York Partnership 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Leeds and York Partnership NHS Foundation Trust (“the Trust’).
1 | CORONER
!am John Hobson, an Assistant Coroner for the coroner area of West Yorkshire
(Eastern).
2 | CORONER’S LEGAL POWERS
I 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 18! March 2019 an investigation was commenced into the death of Miss Layla
Stephanie Dobson, aged 23. The investigation concluded at the end of the inquest on
8" October 2019. The medical cause of death established at the inquest was that Miss
Dobson's died by way of hanging.
A conclusion of suicide was recorded.
4 | CIRCUMSTANCES OF THE DEATH
On 11'* March 2019 Miss Layla Stephanie Dobson was found deceased at her home
address in Headingley Avenue, Leeds. Layla was a student who suffered with mental
health issues and had been engaged with mental health services over the course of a
number of years in her home city of Hull, prior to moving to Leeds.
On 8" February 2019 Layla completed a self-referral form to the Leeds Personality
Disorder Clinical Network (“PDCN”) in which she set out a background including self-
harm and suicidal ideation in the context of a recent relationship breakdown. She
expressed a wish to be supported by the specialist support of NHS mental health
services.
On the section of the form headed ‘Self-harm/suicide (e.g. cutting, misuse of
medication/overdosing and eating difficulties)’ Layla indicated recorded current matters of
‘cutting, recent attempt of hanging, banging head into wall, hair pulling, drugs + alcohol,
restrictive eating’.
Although aspects of the Trust mental health services do accept self-referrals, the PDCN
does not do so to its care co-ordination services. Nevertheless, Layla’s referral was
discussed at a meeting on 25" February 2019 and it was decided that the Clinical Team
Manager, Ellen Scroop would contact the relevant Community Mental Health Team to
discuss whether an assessment of Layla’s needs could be offered.
Miss Scroop gave evidence at the inquest and the question was raised as to any
consideration of a referral to appropriate Crisis Team support, in view of the matters
disclosed by Layla, and specifically to current self-harm/suicide on the referral form.
The records show that contact with the CMHT was followed up in late March 2019.
Evidence was also heard that Layla had appointments with her GP on 1% February,
8 February, 224 February and 8" March 2018. At the last appointment her mental
health and levei of risk was explored and Layla denied any intention of suicide or seif-
harm.
CORONER’S CONCERNS
a
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 matter of concern is as follows. -
Aithough the PDCN considered Layla’s referral, notwithstanding it does not take seif-
referrals to its care coordination services, the evidence provided at the inquest indicated
that there was no formalised or tangible process to guide or otherwise inform practitioners
as to which route of support would be appropriate for an individual.
Whilst the approach to the CMHT was decided upon and actioned, my view upon the
evidence was that the area on the form relating to current self-harm/suicide is not further
flagged or referenced to those taking relevant decisions and this could strengthen the
scrutiny of information when deciding upon which service may be contacted.
Whilst the evidence at the inquest was clear that Layla was under the care of her GP who
later assessed her mentai heaith/risk on 8'* March 2018, | am of the view that the process
whereby an individual seeks to request/access mental services could be strengthened by
| guidance or referencing such that each pathway of support is systematically considered.
{am under a duty to report this matter upon consideration of the evidence.
6 | 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.
|
|
i
| YOUR RESPONSE
~
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Tuesday 11 February 2020. |, John Hobson, the Coroner, may extend the
period.
Your response must contain details of action taken or proposed to be taken, setting out
i the timetable for action. Otherwise you must explain why no action is proposed.
j
|
|
1
! !
8 | COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the family who were an
Interested Party at the inquest.
lam 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 usefut
or of interest. You may make representations to me, the coroner, at the time of your
response, about the reiease or the publication of your response by the Chief Coroner.
me ig
eat
| John Hobson
|__| 46 December 2019 Assistant Coroner
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} Leeds and York Partnership NHS Foundation Trust Date: 11"° February 2020 Leeds and York Partnership NHS Foundation Trust Ref:17524 2150 Century Way Thorpe Park Leeds : 2 LS15 8ZB Mr Kevin McLoughlin Senior Coroner, Western Yorkshire (Eastern District) Coroner’s Office and Court 71 Northgate Wakefield WF1 3BS Dear Mr McLoughlin, RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Layla Stephanie DOBSON, (deceased) Thank you for the correspondence regarding the outcome of the inquest which was concluded on Tuesday 8 October 2019, touching upon the death of Ms Layla Stephanie Dobson. | would firstly like to take this opportunity to express my sincere condolences to Layla’s family and friends at the tragic loss of Layla. Following the Regulation 28 Report to Prevent Future Deaths issued on the 16 December 2019 to Leeds and York Partnership NHS Foundation Trust (LYPFT), please find below the details of the response to address the concerns raised. The Matters of Concern are in bold text with the Trust’s response following: Although the PDCN considered Layla’s referral, notwithstanding it does not take self- referrals to its care coordination services, the evidence provided at the inquest indicated that there was no formalised or tangible process to guide or otherwise inform practitioners as to which route of support would be appropriate for an individual. Whilst the approach to the CMHT was decided upon and actioned, my view upon the evidence was that the area on the form relating to current self-harm/suicide is not further flagged or referenced to those taking relevant decisions and this could strengthen the scrutiny of information when deciding upon which service may be contacted. integrity | simplicity | caring Page 1 of 3 Whilst the evidence at the inquest was clear that Layla was under the care of her GP who later assessed her mental health/risk on 08th March 2018, | am of the view that the process whereby an individual seeks to request/access mental services could be strengthened by guidance or referencing such that each pathway of support is systematically considered. The Personality Disorder Clinical Network service has carefully considered the matters of concerns outlined and agreed an action plan (appendix 1) at the service Clinical Governance forum held on the 30th January 2020. Firstly the service is developing guidance to further inform the decision making process with regards to referral to relevant crisis support services. The guidance will include for example: e Ascertaining whether an imminent risk of suicide is identified in the referral information. e Whether mental health service support is already currently available for the service user. e Whether the referral is a ‘self-referral’. This guidance will routinely be considered at the referral meeting stage and is intended to support decisions taken by the membership of the referral meeting as to a proportionate response to the risk information available at that point in the referral process. It will include reference to recommended ‘steps’ to consider should a referral be identified as indicating an imminent risk of suicide and where support from appropriate mental health services is not already in place. Reference to this guidance will then be routinely made in the clinical case record pertaining to each referral. The service is also aware that there may be instances where the referral may not be considered by the referral team for up to 7 days or where direct contact with the service user was considered the most appropriate course of action and they ‘did not attend’. As such the service referral form and information leaflet (available via the LYPFT website) will be updated to provide details of relevant crisis support services in Leeds. The service will additionally change its process for responding to self-referrals by developing a standard referral receipt letter which will automatically be emailed and/or posted to service users outlining relevant crisis support services. This measure is intended to additionally ensure that service users referred to the service will always be made aware of the relevant services in the City who may be able to provide a crisis service level of response, pending the referral outcome. | hope that this response provides assurance of improvement, consistent with the concerns highlighted in the Regulation 28. We would be pleased to provide any further information or clarification required. Yours Sincerely (~ Dr Sara Munro Chief Executive c.c Mr John Hobson, Assistant Coroner Page 2 of 3
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