Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0426, written 6 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 | 6 Dec 2019 |
|---|---|
| Reference | 2019-0426 |
| Deceased | Safoora Alam |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Community health care · Suicide (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: 1. Chief Executive, Sandwell Council and Director of Social Services 2. Chief Executive, Black Country Partnership NHS Foundation Trust 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 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 the 30 January 2019, I commenced an investigation into the death of Ms Safoora Alam. The investigation concluded at the end of the inquest on 8 November 2019. The conclusion of the inquest was a short form conclusion of suicide. The cause of death was: 1a b Inhalational Burns Severe Flame Burns 4 CIRCUMSTANCES OF THE DEATH i) Ms Alam had complex physical health problems which included a reported diagnosis of Ehlers Syndrome and Fibromyalgia. She had previously suffered a stroke and had on-going complications including pain and mobility issues. ii) She had become increasingly frustrated about her accommodation and her perceived lack of engagement by the agencies involved in her care to find practical solutions to help her with her physical health needs. These included the provision of a ramp. She ultimately decided she would prefer to be in supported accommodation. iii) On several occasions she had threatened to self-harm and had taken impulsive overdoses. A referral was made to the mental health team and the Consultant Psychiatrist’s assessment at this time (12 December 2018) indicated that the patient was not suicidal, not depressed, and not psychotic. iv) The Consultant Psychiatrist recorded that the patient was projecting responsibility to services, had traits of personality disorder, was angry and abusive. v) On the 7 January 2019 a further referral was made to the Crisis Home Treatment Team (CHTT) after another overdose attempt. She denied any 1 [IL1: PROTECT] on-going suicidal ideation and was discharged back to her GP. vi) On the 25 January the CHTT were contacted by the Social Worker. The patient had attended Russells Hall Hospital via an ambulance after having been found by her carers with her gas cooker left on and a lit cigarette. Her gas supply was disconnected, and she was given an electrical fan heater. vii) She was visited by the CHTT again and reported fleeting suicidal thoughts due to her physical health problems. She reported no active plans to end her life at the time of the assessment. Her risk of suicide was deemed to be low, however it was noted that this could be escalated due to impulsive behaviours. viii) On the morning of the 28 January 2019 she had a visit from her Social workers for an assessment. However, this wasn’t completed due to a reported hostile reception they received. ix) She was further visited by housing officers from the local authority and they noted a worrying decline in her mental state and referred her through to their safeguarding department and her GP for a mental health assessment. x) She was last visited by her carers in the afternoon and seemed to have been in better mood. Later that afternoon, she was discovered in her bedroom and had set fire to her bed and herself. She sustained at least 80% burns to her body and sadly died from her injuries later that day at Queen Elizabeth Hospital. 5 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. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the agencies involved. 2. There was a lack of a joint Mental Health Trust and social care packages for patients with complex physical health needs or opportunities to convene multi- agency meetings. 3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took place. 4. The Local authority housing officers did recognise the escalating risk in her mental health state but the mechanism for urgent referral via the safeguarding team and GP was a slow and cumbersome process which didn’t work. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 2 [IL1: PROTECT] 1. All agencies involved may wish to consider reviewing their approaches to sharing of information and approaches to multidisciplinary risk assessments for patients with these complex needs. 2. Social Services may wish to consider reviewing their training for the social workers involved and the importance of obtaining accurate and up to date information prior to any visit. 3. The Mental Health Trust in conjunction with the local authority may wish to consider reviewing their joint agency protocols and developing multi-agency protocols to learn from this tragic incident. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 February 2020. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. I 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. 9 6 December 2019 Mr Zafar Siddique Senior Coroner Black Country Area 3 [IL1: PROTECT]
2 responses 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.
Monday 10th February 2020
Mr Zafar Siddique,
Black Country Area Coroner,
Black Country Coroner's Court
Jack Judge House
Halesowen Street
Oldbury
West Midlands
B69 2AJ
Dear Mr Siddique,
Headquarters
Delta House
Delta Point
Greets Green Road
West Bromwich
B70 9PL
Tel: 0845 146 1800
Fax: 0121 612 8090
Web: www.bcpft.nhs.uk
Re. Regulation 28 report, prevention of future death pertaining to Ms
Safoora Alam, deceased.
Firstly on behalf of Black Country Partnership NHS Foundation Trust may I
extend our most sincere condolences to the family of Ms Alam.
During the course of the inquest the evidence revealed matters giving rise to
concerns in such a way that there is a risk that future deaths will occur unless
action is taken. In response to your regulation 28 report to prevent future
deaths we have outlined below the actions, Black Country Partnership has
taken with the Local Authority to address the matters of concern that affected
our organisation.
1. All agencies involved may wish to consider reviewing their approaches
to sharing of information and approaches to multidisciplinary risk
assessments for patients with these complex needs.
Currently both organisations hold multidisciplinary risk assessment meetings in
isolation, particularly since the section 75 agreement was disbanded. There is
recognized a difficulty in communication between departments in this matter
which needs to be resolved. As a response, the General Manager for BCPFT
Urgent Care Services has met with the Service Manager for Clinical Services
from the Local Authority to examine how our individual organizational
processes can be optimized and joined going forward in order to prevent gaps
in services.
Both senior managers were able to identify common goals and aims in existing
organizational protocols and will instigate a steering group of senior clinicians
and managers from both organisations to look at introducing joint complex care
panels that will look at risk assessments for patients with complex needs that
require joint information sharing and joint working.
It is proposed that these joint multidisciplinary complex case panels will occur
monthly and be chaired on a rotational agreement by a General
Manager from Black Country Partnership and Service Manager from the Local
Authority. The joint multidisciplinary panel will determine which is the lead
organisation in each case where there is disagreement and also ensure that the
joint resources from both organisations are employed when discussing
individual care plans and risk assessments.
2. Social Services may wish to consider reviewing their training for the
social workers involved and the importance of obtaining accurate and up
to date information prior to any visit.
This concern and supporting action is for the Local Authority to respond to.
3. The Mental Health Trust in conjunction with the local authority may wish
to consider reviewing their joint agency protocols and developing multi-
agency protocols to learn from this tragic incident.
The section 75 agreement whereby the local authority delegates responsibility
to the local NHS organisation in this case Black Country Partnership has been
disbanded. This has meant that services have developed independently from
each other and that where services and departments used to work together
and oftentimes cohabit office space, this no longer happens. Both
organisations have joint protocols for working together but in a majority of
cases, it is accepted that staff do not understand their counterpart service nor
who to contact in the local authority and vise versa.
The General Manager for Urgent Care Services for Black Country Partnership
and the Service Manager for the Local Authority have met to examine
communication and interface between the two organisations. They agreed
that communication and interface is often poor due to that both organisations
have different departments and terminology in services which can cause
confusion. This is augmented by the fact that staff and senior staff are not
aware of who their counterpart is and how to contact them in some cases.
The General Manager for Black Country Partnership and the Service Manager
for the Local Authority have agreed to set up task and finish groups to look at
joint agency protocols in both organizations and review them. Furthermore,
they agreed that there should be a joint database or protocol which contains
all contacts and services that each organisation provides. This will provide
staff with an up to date contact list of services in order to support and promote
joint working.
Both senor managers agreed to include on the database and in joint agency
protocols the hierarchy and structures of services so that there is a
governance and escalation process.
Please note that concern number 2 is for the local authority to examine and
therefore BCPFT have not commented on this outcome.
The senior managers also agreed to consider
engaging in a wider learning event to consider outcomes and where future
processes can be continued to be strengthened.
I hope this provides you with assurance that the Trust has taken the
concerns raised in your regulation 28 response very seriously and will
continue to take action to reduce the likelihood of a similar incident from
reoccurring. We hope that the actions highlighted above will make a
difference and we will review changes made at regular intervals to ensure
that they are embedded whilst sharing the outcome and lessons learnt
with all affected staff.
Yours sincerely,
Mark Axcell
Chief Executive
IL2 - Protect Mr Zafar Siddique Senior Coroner Black Country Area Coroner’s Court Jack Judge House Halesowen Street Oldbury B69 2AJ Dear Mr Siddique Our Ref: Your Ref: SJL/SAG Matter being dealt with by: Telephone: Date: 31 January 2020 Thank you for your report regarding Ms Alam’s inquest, and the concerns raised from the evidence revealed during the course of the inquest. I can confirm the Service Manager from Social Work and Therapy has reviewed the concerns and actions identified, which has resulted the following outcomes. In relation to our approaches to sharing information of risk. The Service Manager of Social Work and Therapy, and the Service Manager of Neighbourhoods have met and reviewed the identified concerns and actions within the report. As a result an operational group has been set up to explore and develop a vulnerable adult risk management protocol. In relation to point 2, an action for Social Services to consider reviewing their training for social workers, obtaining accurate and up to date information prior to any visit. A review of our current practice guidance is being undertaken, and lessons learnt will be shared with all staff groups, through team meeting sessions. Sandwell Metropolitan Borough Council P.O. Box 2374, Sandwell Council House Oldbury, West Midlands, B69 3DE (Post Code for SAT NAV B69 3DB) Email: Web: www.sandwell.gov.uk Director of Adult Social Care In order to be assured of the robustness of our joint agency protocols. I can confirm the Service Manager of Social Work and Therapy has made contact with Urgent Care Manager, Mental Health Trust, and there are plans in place to undertake a review of our current protocols within the next four weeks. I trust the information provided will satisfy you that we have acknowledged and responded to the concerns and actions identified. Yours sincerely Director of Adult Social Care cc: David Stevens, Chief Executive
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