Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0155, written 23 Apr 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Apr 2020 |
|---|---|
| Reference | 2020-0155 |
| Deceased | Patricia Ferguson |
| Coroner | Gordon Clow |
| Coroner area | Nottinghamshire & Nottingham |
| Category | Mental Health related deaths · Suicide (from 2015) · Community health care |
| Organisation named | Nottinghamshire Healthcare NHS Foundation Trust |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Bassetlaw Clinical Commissioning Group 2. Mansfield and Ashfield Clinical Commissioning Group 3. Newark and Sherwood Clinical Commissioning Group 4. Nottingham North and East Clinical Commissioning Group 5. Nottingham West Clinical Commissioning Group 6. Rushcliffe Clinical Commissioning Group 7. Nottingham City Clinical Commissioning Group 1 CORONER I am Mr. Gordon Clow, 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 An inquest was opened into the death of Patricia Ferguson on the 9th May 2019 and concluded on the 15th August 2019. The conclusion of the inquest was that the death was suicide. Prior to the death Patricia Ferguson had been in receipt of secondary mental health services from her local Community Mental Health Team. The care afforded by the clinicians working with Patricia Ferguson was good. The psychiatrist and community psychiatric nurse working with Patricia Ferguson formed the clinical view that she would benefit from direct work from a clinical psychologist. A clinical psychologist was not, however, available to carry out direct work. 4 CIRCUMSTANCES OF THE DEATH Patricia Ferguson suffered significant mental ill health at times. She was admitted as an inpatient on one occasion and on other occasions she received secondary mental healthcare including medication, regular review from a Consultant Psychiatrist and support from Community Psychiatric Nurses. When unwell, Patricia Ferguson would typically be overwhelmed with negative thoughts and emotions on a particular issue. This led to her completed suicide. The clinicians working with Patricia Ferguson considered that the particular type of interventions which can only be undertaken by a clinical psychologist would be of benefit to Patricia Ferguson. The inquest heard evidence from Nottinghamshire Healthcare NHS Trust regarding staff establishment within CMHTs. A clinical psychologist was employed by the CMHT working with Patricia Ferguson but was unable to take on new patients as there was going to be a planned period of extended absence. The inquest heard evidence that clinical psychology was a ‘precious resource’ within the CMHTs. In terms of clinical psychology posts, the inquest heard that in some CMHTs within Nottinghamshire there is a full time equivalent post and in other teams this may be a shared post, or a less than full-time equivalent post. No teams have more than one clinical psychologist. I was satisfied that Nottinghamshire Healthcare NHS Trust have implemented measures to make the best use of their clinical psychologists by means of a new internal protocol. 1 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) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation that there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular. (2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths. 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. You should consider whether or not commissioning arrangements for CMHTs represent an appropriate balance of available resources in line with the best available guidance. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18th June 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: Patricia Ferguson’s next of kin Nottinghamshire Healthcare NHS Trust 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 23rd April 2020 Mr. Gordon Clow 2
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.
NR/SB/Clow
4th June 2020
Mr Clow
Sent via Email
Dear Mr Clow
Retford Hospital
North Road
Retford
Nottinghamshire
DN22 7XF
Tel: 01777 590035
www.bassetlawccg.nhs.uk
Re: Regulation 28: Report to prevent future deaths
I am writing in response to the Regulation 28 report to prevent future deaths that was
received by NHS Bassetlaw CCG on 23rd April 2020, information has been provided
on each of the points that were raised and is outlined below.
In the Regulation 28 report to prevent future deaths you stated that:
1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners
of Community Specialist Mental Health Services expresses an expectation that there
would be more than one clinical psychologist for each Community Mental Health
Team, given that clinical psychologists are referred to in the plural within discussions
of an appropriate staff team for CMHTs whereas, for example, consultant
psychiatrists are referred to in the singular.
(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment
of, at most, one clinical psychologist per team, with some teams having only a part
time clinical psychologist post. This inevitably results in some patients, as here,
having no access to clinical psychology when this is clinically indicated, creating an
ongoing risk of preventable future deaths.
NHS Bassetlaw CCG (BCCG) has taken the following actions with regard to this
issue;
The BCCG is working in partnership with Nottinghamshire Healthcare NHS Trust
(NHT) on a programme of transformation to meet the requirements of the NHS Long
Term Plan (LTP) over the next 5 years.
The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core
community mental health teams, increasing team capacity and appointment
availability. In 2019/20 this included funding for additional Clinical Psychology posts
alongside other posts (i.e. pharmacy technicians and administrative support) to
support testing new delivery models.
Continued…….
Dr
Chair
Chief Officer
The LTP is explicit on how community mental health teams need to be developed,
with delivery milestones from 2019/20 to 2023/24 (appendix 1).
includes
The LTP has a strong emphasis throughout on ensuring the provision of high quality,
evidence-based mental health services which
to
psychological therapies within the community based offer, as well as an increased
focus on psychologically formed therapeutic interventions and care plan formulation
through multi-disciplinary team approaches. There is planned investment each year
to deliver the LTP ambitions, which includes increased Clinical Psychology provision
across a range of services provided by NHT. The delivery of services is monitored by
the BCCG and the Transformation plan is reviewed by NHS England on a monthly
basis. BCCG have planned monthly transformation meetings with NHT commencing
which were due to commence in March 2020. However, this has recently been
impacted by the COVID-19 pandemic and has commenced week of 1st June 2020.
increased access
Currently, there is an agreed specification for community mental health teams which
Healthcare NHS Trust use clinical judgement to determine the exact level of staffing
resource required to deliver the aims, objectives and outcomes stipulated within the
service specification.
The Long Term Plan, which I have referenced above, provides a blueprint for
standardised service delivery models to be implemented across England, ensuring
evidence based models of care are commissioned and delivered, progress to
implement a revised service model has already been made in Nottinghamshire.
I hope that this information provides assurance that the BCCG is taking the required
action to address your concerns. Please do not hesitate to contact me if you require
any additional information.
Yours Sincerely
Chief Officer
NHS Bassetlaw CCG
Dr
Chair
Chief Officer
1 Standard Court Park Row Nottingham NG1 6GN Telephone: Email: @nhs.net Date: 09 June 2020 Sent by email to: @nottinghamcity.gov.uk Dear Mr Clow Regulation 28: Report to prevent future deaths– Patricia Ferguson I am writing in response to the report that was received by Nottingham and Nottinghamshire CCG on 23rd April 2020, please note that this response covers Nottingham and Nottinghamshire CCG; Bassetlaw CCG have a separate contract with Nottinghamshire Healthcare NHS Trust. Information has been provided on each of the points that were raised and is outlined below. In the report you stated that: 1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation that there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular. (2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths. The CCG was asked to take the following action; In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. The CCG is working in partnership with Nottinghamshire Healthcare NHS Trust (NHT) on a programme of transformation to meet the requirements of the NHS Long Term Plan (LTP) over the next 5 years. The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support testing new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1). The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence- based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment each year to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the CCG and the Transformation plan is reviewed by NHS England on a monthly basis. A Steering Group meets on a monthly basis to oversee the transformation of the Adult and Older Adult Community model. However, this has recently been impacted by the COVID-19 pandemic and will recommence in due course. Currently, there is an agreed specification for community mental health teams which outlines the aims, objectives and outcomes for the service. Nottinghamshire Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification. The Long Term Plan, which I have referenced above, provides a blueprint for standardised service delivery models to be implemented across England, ensuring evidence based models of care are commissioned and delivered, progress to implement a revised service model has already been made in Nottinghamshire. I hope that this information provides assurance that the CCG is already taking the required action to address your concerns. Please do not hesitate to contact me if you require any additional information. Yours sincerely Chief Commissioning Officer NHS Nottingham and Nottinghamshire CCG Enc. Appendix 1- Long Term Plan- Planning and Delivery Requirements for Adult Severe Mental Illness Community Care 2019/20 Stabilise and bolster core community mental health teams 2020/21 Stabilise and bolster core community mental health teams Ambition Integrated primary and community care for adults and older adults with SMI access 2021/22 At least 126,000 adults and older adults with SMI (including care for people with eating disorders, mental health rehabilitation needs and a ‘personality disorder’ diagnosis) receiving care from integrated primary and community mental health services 2022/23 At least 257,000 adults and older adults with SMI (including care for people with eating disorders, mental health rehabilitation needs and a ‘personality disorder’ diagnosis) receiving care from integrated primary and community mental health services 2023/24 At least 370,000 adults and older adults with SMI (including care for people with eating disorders, mental health rehabilitation needs and a ‘personality disorder’ diagnosis) receiving care from integrated primary and community mental health services
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