Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0468, written 9 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Oct 2019 |
|---|---|
| Reference | 2019-0468 |
| Deceased | James Frankish |
| Coroner | Elizabeth Didcock |
| Coroner area | Nottinghamshire |
| Category | Care Home Health related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dame Sally Davies, The Chief Medical Officer for England 2. 3. President of The Royal College of Psychiatrists Chair of Council, The Royal College of General Practitioners 4. 5. 6. 7. President of The Royal College of Physicians President of The Royal College of Paediatrics and Child Health President of The British Psychological Society President of The Royal College of Speech and Language Therapists 8. Caroline Stevens, the Chief Executive of the National Autistic Society (NAS) 1 CORONER I am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire 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 1st September 2016 I commenced an investigation into the death of James Frankish. The investigation concluded at the end of the inquest on 31st October 2017.The conclusion of the inquest was a Narrative as follows: James Frankish died on the 29th August 2016, following a sudden collapse at Beeches Residential Home. James was the subject of a Deprivation of Liberty Safeguard Order at the time of his death. James had severe autism and a learning disability and was diagnosed with Pica at the age of three, and regularly ate indigestible objects, particularly plant material. In the last few months of his life, James was apparently well. On the evening prior to his death, James vomited plant material, and expelled a hard plant mass (a phytobezoar) from his stomach into his oesophagus, causing sudden obstruction and he died shortly thereafter. James’s Pica and eating behaviours were not fully understood, nor managed, by staff that had care of him at Beeches. 4 CIRCUMSTANCES OF THE DEATH James was aged 21 when he died. He had severe autism, severe Intellectual Disability and Pica- a condition where individuals persistently eat non-nutritive substances. James was a highly complex and vulnerable young man. He was very well understood by his parents, who understood that he was compulsive in his Pica behaviour, and would take any opportunity to grab and eat all kinds of things, but particularly plants and leaves. By contrast, none of the professionals involved in James’s care fully understood the severity and extent of his Pica, nor appreciated it was a life threatening condition. James had required specialist education throughout his childhood. He was non- verbal, but those who knew him could understand and interpret his communications. He was diagnosed with autism and with Pica around the age of 3. His Pica behaviour had included many different objects over the years, and he was very quick to eat and 1 swallow. He was seen by many different professionals over the years, and did not appear to have any symptoms from the developing phytobezoar. By the time of his death this accumulation of hard plant material was of significant dimensions 20x10x5cm. James moved to the Beeches in April 2016. The staff who cared for him there were aware that James had Pica, but did not understand the significance of it, the risk it posed, and particularly the need for constant monitoring and management of the condition. On the day of his death James ate a significant amount of green leaf material. This together with the longstanding phytobezoar likely irritated the stomach lining, inducing vomiting and then oesophageal obstruction, from the vomited bolus of plant material. Cambian Adult Services who were the provider of The Beeches residential home, completed a full review of the circumstances of James death, and submitted additional statements following the Hearing that demonstrated significant learning, and improvements. This went some way to addressing concerns raised in evidence. In my view, however, there remain outstanding concerns that allow for the continuation of circumstances creating a risk that other deaths will occur if such matters are not addressed. Further detail regarding the circumstances of James sad death are included in the attached judgment. 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) Professionals who cared for James did not understand how dangerous Pica can be, ie that it carries significant health risks, including the development of a bezoar. This included the GP, Paediatrician, Psychiatrist, Speech and language therapist, Clinical Psychologist. (2) That there is no national or professional guidance about identification, assessment and management of Pica, with no guidance about how best to understand and manage risk in this condition (3) That there is no national or professional guidance for monitoring for the possible development of a bezoar in an individual who has Pica. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5th December 2019. 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. For the avoidance of doubt, I will require a response from all the Royal Colleges and the NAS to point 1) above. In my view awareness raising of this condition is necessary across all disciplines. I require a response from the Chief Medical Officer to 2 points 2) and 3) above, however, respondents are at liberty and encouraged to respond to all of the issues raised. Respondents may consider it advantageous to consider some of these issues jointly as well as individually. Should respondents favour supplementing their individual responses with a joint response, such a collaborative approach would be greatly welcomed but there is of course no obligation to do so. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: James parents, Next of Kin) 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 9th October 2019 Dr E A Didcock 3
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.
Dr Elizabeth Didcock Assistant Coroner HM Coroner's Service The Council House Old Market Square Nottingham NG1 2DT 20th January 2020 Dear Dr Didcock, Regulation 28 report re: James Mark Frankish Thank you for issuing the British Psychological Society with a report regarding prevention of future deaths arising from the inquest that you conducted into the death of James Frankish. I am writing further to the initial response provided by our Chief Executive, dated 3rd December 2019. , I have spent some time personally, and in discussion with relevant colleagues, reflecting on the issues raised in your report and what the British Psychological Society could do to prevent future deaths under similar circumstances. As you will be aware, over recent years there have sadly been a number of other preventable deaths of people with intellectual disabilities and/or autism in health or social care settings. We are extremely concerned about this fact, which we believe represents a serious health inequality in the United Kingdom. Your report notes that the tragic death of James Frankish at the age of 21 was the result of ingestion of a large amount of non-edible plant material. James had severe intellectual disability and autism; he had also been diagnosed with the eating disorder Pica at the age of 3. Although his parents understood the risks associated with Pica, you reported that the residential care staff and health professionals who were involved with James’ care at that time of his death (which included a Clinical Psychologist), were not aware of the extent of James’s Pica nor did they fully appreciate the risks associated with Pica. Every Clinical Psychology doctoral training programmes in the UK is accredited by the British Psychological Society, the criteria for accreditation specify that “the clinical psychology curriculum should include…… presentations of those with intellectual disability” (p23) and that “Programmes must ensure that trainees gain the following clinical experience and skills” 1 including with “service users across a range of levels of intellectual functioning over a range of ages, specifically to include experience with individuals with developmental intellectual disability and acquired cognitive impairment” (p26). Thus, all Clinical Psychologists trained on accredited courses should have foundational knowledge and skills for working with people with intellectual disabilities. The Society does not specify detailed content for training curricula, but Good Practice Guidance produced by the DCP Faculty for People Intellectual Disabilities mentions “possible physical and mental health problems and disabilities co-occurring alongside learning disabilities” (3.6). This would encompass a range of challenging behaviours and should include Pica. In light of your report, I have written personally to the programme directors of every UK Clinical Psychology training programme to ask them to confirm that Pica, and the associated health risks including risk of mortality, are explicitly addressed in teaching on their programme. Furthermore, I have also circulated to programme directors two articles written by British Psychological Society member, and Chartered Clinical Psychologist, together with James’ parents, Pica, that were published by the National Autistic Society in April 2019 (see attached). , on James’ death and guidance on managing , Psychologists can also contribute to prevention of deaths in similar circumstances more broadly by promoting person-centred care planning that can build on professionals, individuals’ and their families’ expertise, to enhance safety and quality of life. A particularly tragic aspect of James’s death was the fact that his parents’ understanding of the extent of their son’s Pica, and the risks associated with this, was not transferred to the staff caring for James in the residential setting. Whilst awareness is clearly a key issue in the prevention of future deaths, awareness is not sufficient; safe and effective management of behaviours is also critical. Pica would be considered a challenging behaviour and it is important that challenging behaviours are managed using effective, evidenced-based approaches. Positive Behaviour Support is a wrap-around model of care that is recommended in the BPS/Royal College of Psychiatry joint guidelines “Challenging Behaviour: a unified approach” (2007/2016) and the NICE guideline NG11 “Challenging Behaviour and People with Severe Learning Disabilities”. This approach should now be well established in statutory residential care settings, however we are highlighting the need to enhance community provision of Positive Behaviour Support as the Transforming Care programme reduces hospital admissions under the Mental Health Act for people with intellectual disabilities and/or autism who present with acute episodes of severe behavioural difficulties. Clinical psychologists should not only adhere to high standards in their own direct clinical work but can also contribute to the safe and effective functioning of teams with whom they work. One of the nine core competences specified in the BPS accreditation criteria for clinical psychology training programmes is “Organisational and systemic influence and 2 leadership”. The criteria require that all trainlines should develop competence in “Indirect influence of service delivery including through consultancy, training and working effectively in multidisciplinary and cross-professional teams. Bringing psychological influence to bear in the service delivery of others.” In my letter to clinical psychology course directors I emphasised that clinical psychologists can play a role in preventing tragic deaths such as James’, and others of people with intellectual disabilities, through their application of their knowledge and skills directly in the care of that client and also indirectly in promoting person-centred care and appropriate management of challenging behaviours within the services that they have input to. In recent years health and care professionals in the field of intellectual disabilities have set an excellent example of interprofessional working to improve service user outcomes and the British Psychological Society has supported the Learning Disabilities Professional Senate since its inception. We will actively support the development and dissemination of multi- professional guidelines relating the management of Pica. Please do not hesitate to contact me if you would like any further information on any of the above. Yours sincerely, President British Psychological Society 3
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