Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0026, written 11 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2020 |
|---|---|
| Reference | 2020-0026 |
| Deceased | Gemma Azhar |
| Coroner | Bridget Dolan QC |
| Coroner area | West Sussex |
| Category | Suicide (from 2015) · Mental Health related deaths · Community health care |
| Organisation named | Sussex Partnership NHS Foundation Trust |
| 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 THIS REPORT IS BEING SENT TO: The Chief Executive, the Sussex Community NHS Foundation Trust 1 CORONER I am Bridget Dolan QC, Assistant Coroner for West Sussex 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 05 November 2019 I commenced an investigation into the death of Gemma Elizabeth Azhar aged 37. The investigation concluded at the end of the inquest on 11 February 2020. The conclusion of the inquest was that Gemma Azhar died by suicide. 4 CIRCUMSTANCES OF THE DEATH On 9 August 2109 Gemma Azhar had self-referred to the Sussex Community NHS Foundation Trust’s ‘Time to Talk’ service (‘TTT’). During a brief telephone call on 15 August 2019 Gemma Azhar informed a TTT duty worker that she had long term anxiety and depression and was currently experiencing acute distress in the context of marital problems and had previously been seen by her local CMHT. Gemma Azhar was offered a telephone assessment appointment with TTT in a month’s time (on 16 September 2019). On 16 September 2019 Gemma Azhar’s appointment was cancelled by TTT. It is not clear why this appointment was cancelled but it may have been that there had been an error in the booking process and no therapist was available. An administrator spoke to Gemma Azhar informed her of the cancellation and offered a further assessment appointment on 30 September 2019. On 30 September 2019 Gemma Azhar’s assessment appointment was cancelled for a second time by TTT due to the designated therapist being unwell. Gemma Azhar was informed of this second cancellation in a telephone call made by an office administrator. A further assessment appointment was offered which Gemma Azhar declined. As the communication with Gemma Azhar was through an administrator no questions were asked of Gemma Azhar as to how she was feeling or why she was now declining the offer of a third date for an assessment. Gemma Azhar was then discharged from the TTT service. Although a duty therapist was on duty on 30 September that therapist was not asked to speak to Gemma Azhar. Therefore, no assessment of Gemma Azhar’s current mental state or her current level of risk was attempted before she was discharged from the service. On the evening of the 31st October 2019 Gemma Azhar was found hanging in the garage at her home address. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: Those in need of the TTT service and support may feel discouraged from engaging with the service and be left at risk in the community if, when repeated cancellations occur, they are spoken to only by an office administrator, who is not in any position to enquire about their mental health or make any assessment of their current condition. , the Clinical Lead for the Time to Talk service in the North Area, of gave evidence at Indeed Gemma Azhar’s inquest and informed me that in her view, the service “did not get it right”. She stated that given that the TTT service had cancelled Ms Azhar‘s apppointment twice, it would have been preferable if there had been attempts made to find her an alternative therapist on 30 September 2019 and, if none was available, for a duty worker to have spoken to Gemma Azhar before she was discharged from the service in order to understand: the reasons for her now declining a third appointment; her current mental state and, if appropriate, seek to engage her and assess her present risk. informed me that it was now the ‘formal’ position that this should happen after a second cancellation by the service. However, it is a matter of concern to me that staff working in the North area (Horsham, Crawley and Mid Sussex) have only been notified of this ‘formal position’ by an email sent in or around December 2019. This procedure is not part of any written policy or protocol or induction training and therefore new staff in the North area would only learn of the procedure by word of mouth. Furthermore, Community NHS Foundation Trust’s staff working for the TTT service in other areas. was not aware whether or not a similar instruction had been given to the Sussex 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 April 07, 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: I have also sent it to may find it useful or of interest. (parents) and , the Clinical Lead for the Time to Talk service in the North Area, who (Ms Azhar’s husband). 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 Bridget Dolan QC Assistant Coroner for West Sussex, Bridget DOLAN, QC Assistant Coroner for West Sussex Coroner's Service Dated: 11/02/2020 Dated: 11/02/2020
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.
Trust Headquarters
J Block
Brighton General Hospital
Elm Grove
Brighton
BN2 3EW
www.sussexcommunity.nhs.uk
01273 265930
Private & Confidential
Ms Bridget Dolan QC
Assistant Coroner
Coroner’s Service
County Record Office
Orchard Street
Chichester
West Sussex
PO19 1DD
Your ref: 02719-2019
Our ref: GA 337
2 April 2020
Dear Ms Dolan
Inquest into the death of Gemma Elizabeth Azhar
I am writing further to my letter of 26 February 2020, in response to the issues raised in your
Regulation 28 report. I am grateful to you for raising these matters and for the opportunity
this has provided to review our Time to Talk Service procedures in relation to discharge of
patients. Once again, I wish to express my condolences to Gemma’s family and friends for
their sad loss and I know this is an extremely difficult and distressing time for them. I would
also like to offer my apologies for the problems that occurred with Gemma’s appointments
and for the fact that we did not communicate more effectively with Gemma. This has
resulted in further discussion and reflection in our Time to Talk service and we acknowledge
that there is important learning from the events surrounding Gemma’s tragic death.
Following the evidence given at the inquest by
and remit of our Time to Talk Service, it may be helpful to provide some further information.
The Time to Talk Service is not a crisis service, and operates a high volume, high
throughput model which receives an average of twenty four thousand referrals each year.
The service is not clinically established to provide urgent support to people with severe
mental health conditions ie. those at a high level of risk of suicide, severe self-neglect,
significant self-harm or harm to others, and significant risk which needs monitoring within a
Clinical Lead, about the role
multi-disciplinary setting, or who would be best supported by a multi-disciplinary approach.
We also ensure that when people self-refer to Time to Talk, they are made aware, through
correspondence and information on the website, that the service is not able to offer urgent
support, and we provide information on how patients can access such support.
The service is required to see 75% of all referrals within 6 weeks and all patients are
routinely informed about how to access more urgent care. If patients have been assessed in
Time to Talk with this level of difficulty, or the referral information and any additional
information indicates an urgent need, they are referred to secondary care services i.e. the
Assessment and Treatment services, run by Sussex Partnership NHS Foundation Trust
(SPFT).
Nevertheless, it was unacceptable to cancel two of Gemma’s appointments at such short
notice. We should have taken a more active approach in maximising the opportunity for a
clinical conversation to explore with Gemma her reasons for declining the offer of a further
appointment with potential to assess the level of risk. Although Gemma did not wish to
agree to a clinical appointment, where risk could have been fully assessed, a phone call
undertaken by a clinician could have potentially promoted engagement and offered
opportunities to clarify her situation and needs.
You expressed concern specifically on the lack of any written, formal process or protocol
addressing situations where two cancellations have occurred and a patient has disengaged
from the service. In addition, you considered that there was lack of evidence that the new
process described at the inquest had been communicated to all staff in the Time to Talk
Service in a structured and formal way.
confirmed at the inquest, Time to Talk staff working in the North Area were
As
notified by email of the new procedure ie. that efforts should be made to find an alternative
therapist to prevent short notice cancellation of appointments and, if no-one was available,
the duty therapist should have further discussion with the patient before any discharge took
place. (This email was sent on 9 December 2019).
I can confirm that the following action has been taken in response to your comments:
(1) A Standard Operating Procedure (SOP) has been created to confirm the processes to
be followed when the Service has cancelled appointments. A separate, existing SOP
concerning patients who do not attend or who cancel appointments has also been updated.
The updated SOP ensures that cancellations of appointments by patients are identified and
includes an additional digital audit system as a weekly measure to monitor numbers.
The new SOP will ensure that administrative staff contact the duty therapist about any
patient in circumstances similar to Gemma (where two assessment appointments have
been cancelled). This will enable the duty therapist to try to promote engagement and
maximise the opportunity for a clinically informed conversation with the patient, with further
action taken as necessary. As a further safeguarding measure, a digital alert system,
coordinated by the data analysts, will provide a process which will alert senior therapists to
Page 2
any patient who has had two appointments cancelled by the service, and who has not yet
been contacted by a clinician.
The new SOP also incorporates a new service resource for patients - reserved assessment
slots. These will be offered on a daily basis and ensure that if the service has to cancel an
assessment for any reason there will be a number of un-booked slots which can be used to
maximise opportunities to offer alternative same day assessments where possible.
The SOP has been reviewed and agreed at the Team Governance Meeting and Area
Governance Meeting. It has now been disseminated to all staff via the senior leadership
team for each locality and has been integrated into team training and formal induction
processes. It is also accessible to all staff via the service shared electronic folder system.
(2) Prior to the inquest, work was also carried out on a SOP regarding clinical notes
guidance for Time to Talk staff, ratified at the Team Governance Meeting on 26 February
2020 and reviewed by the Area Governance Meeting on 20th March. This provides updated
guidance to all staff on writing clinical and administrative notes on our electronic IAPTUS
patient record system. It will ensure that information recorded is consistent and
comprehensive, including confirmation of the reason for any service cancellation. It also
includes guidance on recording any patient risk(s) identified. As above, senior team leads
will ensure that all staff are trained and made aware of this process in each geographical
area and it will be integrated into induction processes for all staff. All staff will access the
SOP via the service shared drive. These actions will be completed by the end of May 2020.
I appreciate that you did not raise the issue of clinical documentation in your letter.
However, I wanted to offer this information as further evidence of the work that is being
carried out continually to improve our systems for patient care and communication.
I hope the actions described above will demonstrate to you and to Gemma’s family that we
have taken very seriously the concerns you raised. If you or Gemma’s family need any
further information, please do not hesitate to let me know. Equally, if there is any support we
can offer to Gemma’s family, we would be very happy to arrange this.
Yours sincerely
Siobhan Melia
Chief Executive
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