Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0071, written 16 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Mar 2020 |
|---|---|
| Reference | 2020-0071 |
| Deceased | John Ashley |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| Category | Mental Health related deaths · Suicide (from 2015) · Community health care |
| Organisation named | Sussex Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Ms Schofield
Senior Coroner West Sussex
Sent by email: penelope.schofield@westsussex.gov.uk
Dear Ms Schofield
Response to Regulation 28 Report dated 16 March 2020
Swandean
Arundel Road
Worthing
West Sussex
BN13 3EP
Tel: 0300 304 0673
11 May 2020
Email:
chiefexecutive@suss
expartnership.nhs.uk
I write formally to respond to your report to prevent future deaths, under Regulation 28
Coroners (investigation) Regulations 2013.
Your report raises the following concerns:
1. Mr Ashley's care and treatment plan was not updated when his mental health
deteriorated;
2. Staff were not recording interactions with Mr Ashley in the Carenotes system, and
often emails were not copied into these notes. Therefore there was a lack of
compilation of key information relating to Mr Ashley;
3. There was no system in place for Lead Practitioners to be notified of an important
entry in a patient's Carenotes where action was required;
4. Mr Ashely had not been seen by a Psychiatrist for over a year and there was no
evidence that the deterioration of his mental health (and his non-compliance with
his medication) had been reviewed by the professionals' weekly meetings;
5. There was a discrepancy in the Trust's own policies as to when a risk assessment
should be reviewed;
6. Save for the duty scheme, there appears to be no procedure in place for another
practitioner to cover a Lead Practitioner's case load or any formal handover when
they are on leave. Therefore there was no single person who has update
knowledge of a patient who may be in need or whose mental health was
deteriorating;
7. The MHLT did not make use of the patient's Care & Support Plans or Central Risk
Assessment;
8. There was no clear procedure for GPs to be updated by Care Coordinators with
details of a patient's current treatment plan if it had changed. This was particularly
important where there was no regular assessments by a Psychiatrist who would in
normal course of events, be providing such updates.
Chair: Peter Molyneux Chief Executive: Samantha Allen
Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP
www.sussexpartnership.nhs.uk
A teaching trust of Brighton and Sussex Medical School
I address your concerns as follows:
1. Updating of care and treatment plans when a patient deteriorates
In the case of Mr Ashley, it is acknowledged that his care plan contained out of date
information and did not accurately reflect his changing circumstances. There were also
missed opportunities to update his risk assessment using the risk event functionality within
our Carenotes system. These concerns were identified in the Trust's Serious Incident
Review and
had responded to those concerns through caseload reviews, clinical records audits and
supervision.
Team Leader, gave evidence at the inquest of how the service
The Trust monitors performance in each of these areas and there are individual
performance dashboards for each team within the Carenotes system that allow clinicians
to monitor their own performance when they log onto the system. Team Leaders and other
managers also have access to team/service based reports through our "Report Manager"
performance system and these provide an audit function and allow managers to have an
overview of team performance.
I am informed that at the inquest,
receive regular clinical and managerial supervision and this allows managers and clinical
supervisors to monitor the quality of someone's work and record keeping as well as
address any concerns about individual practice. This process remains in place with
compliance monitored at a team and Trust level.
was also able to confirm that clinicians
The Trust is continuing to monitor compliance with care plans, risk assessments and
supervision and since autumn last year, we have revised our care plan and risk
assessment formats/processes, updated our policies and training programme to improve
standards of care.
In my letter to you dated 20 December 2019, I detailed some of these steps and I would
like to confirm that the Trust has successfully implemented these changes with a view to
preventing future deaths. Specifically, we have introduced a new universal risk
assessment and this captures risk events in chronological order and improves record
keeping. Although the format of the risk assessment has changed, the principles of robust
risk assessment, remains the same, and our Trust continues to use the '5 P's' risk
formulation model to provide a narrative and summary of the past risks.
We have invested in the recruitment of a Lead Clinician, and they are responsible for
delivering face-to- face risk assessment training, and to date has provided training to over
950 clinical staff. The training utilises national and local learning from serious incidents
pertinent to the clinician's work environment and has been consistently well evaluated.
Page 2 of 6
I regret that the risk assessment was not updated in the records as it should have been in
Mr Ashley's case, however his risks were continually assessed and I understand that this
was accepted by the Coroner's expert,
2. Staff were not recording interactions with Mr Ashley in Carenotes and often e-
mails were not copied into these notes. Therefore there was a lack of
compilation of key information relating to Mr Ashley
It is standard practice for all interactions with patients to be recorded on the Carenotes
system and these records are available and accessible to clinicians in all parts of our
service to review. In the case of Mr Ashley, it was evident that our acute and community
services used his health records to share information, make clinical decisions and review
his care. However, I understand that you had specific concerns that email
correspondence from Mr Ashley's sister, was not uploaded to his record. I would advise
that it is not customary practice to upload all email correspondence. However, the Trust
contact to be recorded on the system.
would expect a record and detail of
At the inquest, staff explained that they use an out of office assistant (automatic reply) to
advise patients, carers or other health professionals of their absence and how to seek help
if required. I understand that the Lead Practitioner used this system whilst he was on
annual leave and
was under the impression that the Trust had a system for monitoring emails of the Lead
Practitioner who was on leave when she sent her emails which isn’t the case but we will
ensure out of office automatic replies are clear in how someone will seek help when the
practitioner is on leave.
was directed to contact a duty worker. However,
The Trust recognises the importance and value of carer involvement, and this is
acknowledged in the Serious Incident Report, specifically the role
caring for her brother. We continue to emphasise the need to actively seek consent from
patients to allow carers and family to participate in their treatment and care. As a result of
this recommendation and learning from other similar incidents, the Trust now provides a
Carer's Pack specifically designed to involve families and carers. The pack provides
information about a carer's entitlement to a carer’s assessment and the relevant local
services they can access for support. I am enclosing a copy of the pack with this letter for
your information. We also have bespoke Carers Training provided by paid Carer Leads,
and local teams have updated their "Triangle of Care self-assessment tools" and
developed action plans to improve carer engagement.
played in
3. There was no system in place for Lead Practitioners to be notified of an
important entry in a patient's Carenotes where action was required
I acknowledge that our Carenotes system does not have an automatic function to alert
Lead Practitioners and/or the clinical care team when another clinician has accessed a
patient's records or recorded clinical activity. However, I would like to reassure you we
have processes and procedures in place to allow clinicians to share information when
Page 3 of 6
required. In the case of Mr Ashley, it is evident that there was sharing of information
between the teams which were involved in his care e.g. the Worthing Recovery &
Wellbeing Team, and Mental Health Liaison Team, shared information when Mr Ashley
used out of hours services and the Lead Practitioner or Duty Worker responded to
concerns and reviewed his treatment and care.
I acknowledge that in this case, it was a specific concern that a Lead Practitioner when
returning from leave should be aware of important developments regarding his/her patient.
It is the responsibility of a Lead Practitioner and other members of staff returning from
leave, to review their caseload and establish if there were any concerns during their
absence and I understand that Mr Ashley's Lead Practitioner did make himself aware of
events when he returned from leave (he addressed this in his addendum report at the
Inquest). Nevertheless, I wish to reassure you, that I agree that it is important that there
should be a handover following a leave of absence, particularly in the case of the most
vulnerable patients and staff are actively encouraged to ensure that this takes place and
this will become part and parcel of staff risk assessment training.
4. Mr Ashely had not been seen by a Psychiatrist for over a year and there was
no evidence that the deterioration of his mental health (and his non
compliance with his medication) had been reviewed at the professionals'
weekly meetings
Mr Ashley had a medical review on 1 August 2017 with a Psychiatrist and should have had
a 12 month follow up review thereafter.
Mr Ashley did have a medical review/telephone consultation with a Consultant Locum
Consultant Psychiatrist on 30 October 2018 when there was a concern about his health.
I regret that Mr Ashely was not seen by a Psychiatrist as regularly as he should have been
i.e annually, however I can report that the Trust has successfully appointed two
substantive Consultant Psychiatrists for Worthing this year, and they joined the team in
March. They are supported by an Associate Specialist. This will enable us to facilitate
medical reviews in a timely manner and negate the need for a waiting list. The medical
caseload is currently being reviewed with a view to ensuring that every patient has an
annual medical review as required.
In respect of your concern that Mr Ashley's condition was not discussed in the
multidisciplinary (MDT) meetings, I would like to reassure you that MDT meetings occur
weekly and Lead Practitioners and other colleagues are invited to present cases where
they require advice and support, or cases which require a multidisciplinary approach. The
decision as to whether a case should be discussed at a MDT meeting, is a matter of
clinical judgment, and in Mr Ashley's case, his Lead Practitioner and others involved in his
care, did not consider this support was necessary and his care was reviewed by the
experienced staff who were directly involved in his care.
My understanding is that it is not common practice for every patient to be discussed at a
MDT meeting.
Page 4 of 6
5. There was a discrepancy in the Trust's own policies as to when a risk
assessment should be reviewed
The Trust accepts that the current Clinical Risk Assessment and Safety Planning/ Risk
Management Policy and Procedure policy is unclear as it has two potential review dates
when the risk assessment should be updated. The current policy is under review and this
has been addressed as part of that. The new policy is in the final stages of ratification and
will be available for staff very shortly.
6. Save for the duty scheme there appears to be no procedure in place for
another practitioner to cover a Lead Practitioner's case load or any formal
handover when they are on leave. Therefore there was no single person who
had up to date knowledge of a patient who may be in need or whose mental
health was deteriorating
This concern was addressed in my letter of 20 December 2019 wherein I sought to convey
that Mr Ashley was treated as part of a team, and that a plan was in place (as part of his
overall care plan), to ensure that there was adequate support when his Lead Practitioner
was not available. Prior to going on leave, I understand that Mr Ashley's Lead Practitioner
visited to discuss cover arrangements and his crisis/contingency plan. It is apparent that
Mr Ashley understood the arrangements as he attended his planned appointments at the
Wellbeing Café and Clozaril Clinic, and he accessed the duty system and the Mental
Health Liaison Team for further support.
I appreciate that there may be some merit in delegating care to an individual colleague
when the Lead Practitioner is on leave, however such a system is not without risk as a
patient may find himself without a contact in the event that the delegated colleague is
himself absent for any particular reason. The duty system will always ensure that there
are experienced mental health practitioners available to respond to an urgent enquiry or
crisis, who will have access to up to date knowledge of the team systems, and how to
access urgent Multi-disciplinary Team care and intervention. Rather than delegating
responsibility to just one individual, the system which is in place, ensures that the team as
a whole will take responsibility to ensure that care is provided, when the Lead Practitioner
is absent. I would also add that the Carer's pack and the Trust's Carer's handbook,
contains guidance on what to do in the event there is concern for the person being cared
for.
7. The MHLT did not make use of the patient's Care & Support Plans or Central
Risk Assessment
was critical of the assessment undertaken by the
I understand that
MHLT and considered that they should have considered the care plans. I would like to
explain that the MHLT has its own assessment format and this includes a risk assessment
and action plan section and is designed in this way for ease of sharing information with
primary care. At the Inquest, I am informed that the MHLT Team Leader gave evidence as
Page 5 of 6
to how he and his colleagues reviewed Mr Ashley's health records and contacted Worthing
Recovery and Wellbeing to agree a treatment plan for him, in the knowledge that his Lead
Practitioner was on annual leave and Mr Ashley required support from a duty worker.
8. There was no clear procedure for GPs to be updated by Care Coordinators
with details of a patient's current treatment plan if it had changed. This was
particularly important where there was no regular assessments by a
Psychiatrist who would in normal course of events, be providing such
updates
Mr Ashley should have had a medical review on an annual basis and I wish to assure you
that it is our practice to send a clinical letter to the GP as well as a copy to the patient. It is
also Trust practice to send a copy of the care plan and information about changes to
medication or physical health assessments undertaken by our service. I am informed that
the GP practice received copies of Trust letters from the last medical review and copies of
the assessments undertaken by the Mental Health Liaison Team and these contained
details of the perceived risk and action plan agreed with the patient.
I do hope that you will be reassured that in light of the recruitment of two Psychiatrists,
going forward, reviews will take place without any undue waiting time and GPs will
continue to be kept informed of all reviews which take place.
I trust this response addresses your concerns and provides you with reassurance that the
Trust takes its responsible to reduce the risk of future deaths seriously. However if any
further clarification is required, please do not hesitate to contact me.
If following receipt of this response you would like to meet with the clinical team to see and
discuss how the various changes have been implemented I would be only too happy to
facilitate this.
Yours sincerely
Samantha Allen
Chief Executive
ENC: Carer's Pack (N.B: to follow hardcopy by post)
Page 6 of 6
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Samantha Allen Chief Executive Sussex Partnership NHS Foundation Trust Swandean Arundel Road Worthing West Sussex BN13 3EP 1 CORONER I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of 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 6th November 2018 I commenced an investigation into the death of John Ashley, aged 57. The investigation concluded at the end of the inquest on 6th December 2019. The conclusion of the inquest was a Narrative Conclusion namely “John Ashley took his own life whilst suffering a deterioration of his mental illness. His deterioration was not fully appreciated by those treating him within the Sussex Partnership Trust and they failed to provide him with the additional level of care that he required. His death was contributed to by neglect. “ Following the Inquest I indicated that I was minded to make a Regulation 28 report but would like to hear submissions from the Interested Persons. An extention for receipt of these submissions was granted to 17th January 2020. I have fully considered the submissions that I have received in preparing this report. 1 4 CIRCUMSTANCES OF THE DEATH 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. Mr Ashley’s Care and Treatment Plan was not updated when his mental health deteriorated. 2. Staff were not recording interactions with Mr Ashley in the CareNotes system and often emails were not copied into these notes. Therefore there was a lack of compilation of key information relating to Mr Ashley. 3. There was no system in place for Lead Practioners to be notified of an important entry in a patient’s CareNotes where action was required. 4. Mr Ashley had not been seen by a Psychiatrist for over a year and there was no evidence that the deterioration of his mental health (and his non compliance with his medication) had been reviewed by the professionals weekly team meetings. 5. The Inquest identified that there was a discrepanciy in the Trust’s own Policies as to when a Risk Assesment should be reviewed. 6. Save for the duty scheme there appears to be no procedure in place for another practictioner to cover a Lead Practictioner’s case load or any formal handover when they are on leave. Therefore there was no single person who has uptodate knowledge of a patient who may be in need or whose mental health was deteriorating. 7. The Inquest heard evidence that the Liasion Mental Health Team at the Hosptial did not make use of patient’s Care and Support Plans or Central Risk Assessment. 8. The was no clear procedure for GPs to be updated by Care Coordinators with details of a patient’s current treatment plan if it had been changed. This was particulary important where there was no regular assessments by a Psychiatrist who would in the normal course of events be providing such updates. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 11th May 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:- Sister of the deceased Leigh Day, Solicitors for the family I am also under a duty to send the Chief Coroner a copy of your response. 2 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 Date 16th March 2020 Penelope Schofield, Senior Coroner 3
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