Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0450, written 20 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 | 20 Dec 2019 |
|---|---|
| Reference | 2019-0450 |
| Deceased | David Fowler |
| Coroner | Rachel Galloway |
| Coroner area | Manchester (West) |
| Category | Alcohol, drug and medication related deaths · Community health care · Mental Health related deaths |
| 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
~T REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
lead of Clinical Services -
TRU (Transitional Rehabilitation Unit), Margaret House, 342 Haydock Lane,
Haydock, St Helen’s, Merseyside WA11 9UY
CORONER
| am Rachel Galloway, Assistant Coroner, for the coroner area of Greater Manchester
West.
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
INVESTIGATION and INQUEST
On the 2"4 January 2019 | commenced an investigation into the death of David Richard
Fowler. An inquest was opened on the 4" January 2019. The investigation concluded
following a 5-day inquest at Bolton Coroner's Court on the 20'" December 2019 and the
conclusion was one of Suicide. The Medical Cause of Death was 1a Multiple injuries.
CIRCUMSTANCES OF THE DEATH
David Fowler (“David”) had a significant history of mental illness. From around 1999,
David had developed problems with both illicit drugs and alcohol consumption. In or
around 2003, David suffered a significant brain injury due to an assault. That brain
injury caused or seriously exacerbated a Personality Disorder. The combination of the
brain injury and Personality Disorder meant that David was impulsive and his alcoho!
and drug misuse problems became more extensive and difficult to manage.
In April 2017, David was referred to and accepted for specialist rehabilitation at the
Transitional Rehabilitation Unit (“TRU”), which was funded by the local Clinical
Commissioning Group. At this stage, David was resident at Newton Unit (a locked
rehabilitation unit) and detained under section 3 of the Mental Health Act 1983. He later
spent time at Lowton Unit (an open rehabilitation ward) before moving to Ashton Cross
on the 12% March 2018. Ashton Cross was a pre-community placement. David
remained under section 3 of the Mental Health Act 1983 but had been granted section
17 leave with a condition that he reside at Ashton Cross.
Throughout his time at TRU, David received significant therapeutic input including help
with problem solving and impulsivity, counselling and planning. There were periods
where David showed improvement and other periods where he would abscond from the
various units and consume alcohol and illicit drugs.
On the 18" December 2018, an inappropriate decision was taken (following a
Multidisciplinary Disciplinary Team Meeting ("MDT”)) that David's “section 3” (and
parasitic “section 17” provisions) would be removed. It was the view of the instructed
_| expert Psychiatrist that the “section” should not have been lifted until there was a plan in
place regarding his community placement and care going forward.
As a result of the decision of the Responsible Clinician at the MDT, David became a
resident at Ashton Cross with no legal framework in place and with no community plan in
place for his future.
The views of David’s family were not sought prior to the decision to lift the section on the
48 December 2018. Further, David's family was not invited to attend the MDT meeting
on the 18" December 2018.
David left Ashton Cross on the 20" December 2018 and was returned by police on the
23 December 2018. David had consumed alcohol and drugs during this period and
been arrested for a criminal offence. His behaviour was escalating but the lack of any
legal framework meant that TRU had limited control over him.
On the 26 December 2018, David left Ashton Cross at 1.30 pm with the intention of
placing a bet on the races. He was a voluntary client at Ashton cross and was entitled to
come and go as he pleased. At approximately 3 pm David fell backwards from a
motorway bridge at junction 24 of the M6 from the A58 (Liverpool Road). In the
moments prior to taking those actions, David likely formed an intention to end his own
life by falling from the bridge. He had not formed any specific intention to end his own
life prior to that.
David died as a consequence of multiple injuries sustained after he fell from a Motorway
Bridge, with the intention of ending his own life. The inappropriate decision to revoke his
detention under section 3 of the Mental Health Act 1983 (eight days prior to his death)
likely contributed to his death. This was the evidence of Professor Shaw, expert
Psychiatrist. | accepted her evidence on that point.
Further, there was a failure invite David's family to that MDT meeting (8 days prior to his
death) but this did not contribute to David's death.
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. —
In David's case, no steps were taken to invite Leena (or any other family
member) to the MDT meeting on the 18" December 2018 when the decision was made
by the Responsible Clinician to remove David from the confines of section 3 (and section
17) of the Mental Health Act 1983. It is a requirement of the Mental Health Act 1983 that
the nearest relative is informed. Further, family views were not sought regarding the
decision to lift the section in any other way. At the inquest, staff remained unclear
between themselves as to whose responsibility it was to inform the family.
Whilst | was informed that a Policy has been drafted and is in the process of being
ratified, it remained the case that there was no formal Policy in place covering contact
with families in respect of the above decisions and/or in respect of inviting family
members to MDTs more generally. | was further concerned that there was on-going
confusion between witnesses (in particular the Acting Manager and the Responsible
Clinician) as to who is tasked with informing the family of MDTs and of any potential
decision to remove a “section”.
L_|
ACTION SHOULD BE TAKEN
{| In my opinion action should be taken to prevent future deaths and | 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 17" February 2019. I, the Assistant 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 the following Interested
Persons (as well as the funding Clinical Commissioning Group for TRU) who may find it
useful or of interest:
(1) EE (through BJC Solicitors)
(2) Liverpool County Council
(3) Clinical Commissioning Group
1 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 assistant coroner, at the time of
your response, about the release or the publication of your response by the Chief
Coroner.
|
9 | Dated 20" December 2019
Sign
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/ WM Lem
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Rachel Galloway
HM Assistant Coroner
| Manchester West _|
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.
14 February 2020 Rachel Galloway HM Assistant Coroner Manchester West HM Coroner’s Court Bolton BL1 1QY Dear Ms. Galloway Re: Response to Regulation 28: Report to Prevent Future Deaths, in relation to the inquest of Mr. David Richard Fowler Deceased. I am writing to provide a formal response to the Regulation 28 for the prevention of future deaths issued to the TRU (Transitional Rehabilitation Unit) LTD following the inquest of Mr. David Fowler. I confirm the following action has been taken in response to the regulation issued: included a revision of procedures There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This team has communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process. regarding multidisciplinary I have attached this revised policy for the organisation involving all TRU services, MH28 Care Planning and Care Coordination policy, as this outlines and clarifies several procedures that are operational in relation to: 1. Communication with family members and statutory professionals. 2. Decision making protocol including a new decision making checklist as seen in appendix 6.0 of the policy, which outlines clear protocol relating to assessment of mental capacity. 3. A revised care planning review form that is utilised for every meeting reviewing a client’s care as outlined in appendix 5.0 and formalises feedback on an ongoing basis from family during weekly, six weekly and formal 1 | P a g e conference meetings. 4. Clarification of roles and responsibilities across team members in relation to care coordination and communication to family members including the Nearest Relative for individuals detained under the Mental Health Act and the next of kin for all individuals. 5. A clear transition planning process to ensure continuity of communication with families and continuity of care planning if an individual transitions from one service to another within TRU. 6. A clear discharge planning process as outlined in the care planning framework summary of appendix 1.0 and within the body of the policy. This includes the aftercare planning procedures undertaken in advance of any individual discharging from a legal framework, including the Mental Health Act, and/or any broader discharge from the service. I have also attached two revised policies specific to care planning policies for adults detained under the Mental Health Act most relevant to this regulation. These are the MH12 Section 117 planning policy and the MH10 Communicating to family and external parties’ policy for people under the Mental Health Act. These two policies outline specifically: 1. The clear and non-negotiable procedure and structure of a 117 planning meeting clearly involving family and statutory professionals. 2. Clarification over specific contact between the treating team and the Nearest Relative in relation to ensuring family members know when care planning reviews are taking place, ensuring their wishes and views are well represented if the family member does not wish or is unable to attend and to ensure clear and timely feedback from any meeting and certainly in respect to any planned discharges from the Mental Health Act. These two policies specific to individuals detained under the Mental Health Act are supplemented by the broader MH28 policy as outlined above in supporting robust care planning and coordination. I confirm there have been regular reviews of these procedures since the inquest and an audit framework has been devised to monitor continued compliance and service delivery in these areas including direct audit of the stages outlined in appendix 1.0 (care planning framework). I also confirm the Responsible Clinician involved in this case has made a referral to the General Medical Council and the individual has undertaken further action related to professional development, supervision and training. I believe the revisions above directly address, and resolve, the concerns raised through the Regulation 28. 2 | P a g e I hope the attached information is informative and outlines these improvements although please let me know if you require further information. Yours sincerely Head of Clinical Services 3 | P a g e
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