Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0204, written 12 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Oct 2020 |
|---|---|
| Reference | 2020-0204 |
| Deceased | Piotr Kierzkowski |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Norfolk and Suffolk 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt Hon Matt Hancock MP Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 24th March 2020 I commenced an investigation into the death of Piotr Marek KIERZKOWSKI The investigation concluded at the end of the inquest on 23rd September 2020. The conclusion of the inquest was that the death was the result of:- Suicide, whilst suffering from a psychotic episode. The medical cause of death was confirmed as: 1a Incised wound to the neck 4 Piotr Kierzkowski was found deceased on the 17th December 2019 at his home address of , Bury St Edmunds in Suffolk. When found, Piotr had barricaded himself into his bedroom which was subsequently forced open by police officers. Officers had been called, as Piotr’s landlady had looked through the window of his ground floor bedroom and seen blood on the bedding and walls. When officers entered, they found Piotr was slumped on the floor with his back against the wall, a large pool of blood surrounded him and a knife was found close to his body. The day before his death (16th December 2019) Piotr, who had a history of mental illness, had suffered a mental health crisis and had been taken to his GP by a concerned friend. His GP immediately referred Piotr for a review by mental health professionals and his friend then took him to the Accident and Emergency department of the West Suffolk Hospital, Bury St Edmunds for this to be undertaken. Once there, Piotr was seen and assessed by mental health practitioners, who wanted to immediately admit Piotr as an informal patient onto the hospital’s Psychiatric Unit. It was also Piotr’s wish that he was admitted as an informal patient. However, the unit was at capacity and no other beds were available within Suffolk itself, or elsewhere in the country at that time. As a result, late in the evening of the 16th December Piotr was sent home with a friend and told to return at 10:00 the next morning when a bed would be available. Piotr was last seen alive outside his bedroom at his home address at approximately 07:00 on the 17th December, before he returned into that room. Piotr took his own life shortly before he was due to be returned to the hospital by his friends. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you; the MATTERS OF CONCERN as follows. – In evidence it was heard that Piotr had not received his ‘depot’ medication for some time and was clearly suffering from a psychotic episode at the time of his assessment at the Accident and Emergency department of the West Suffolk Hospital on the 16th December 2019 Piotr told staff he was not actively suicidal at that point in time, and although the staff were concerned about his presentation, under mental health law least restrictive principles, they did not believe the powers of detention under the Mental Health Act were applicable. That said, it was also clear from the evidence that the mental health personnel who saw Piotr wanted to immediately admit him as an informal patient. It was also clear that when Piotr attended hospital on the 16th December 2019, he too wanted to be immediately admitted as an informal patient. As a result, staff tried to locate a bed for Piotr so he could be admitted as all involved wished. However, it was identified that there were no beds available in Suffolk, or anywhere else in the country at the time. Different options of keeping Piotr in the hospital were explored but none were viable. As such, Piotr was prescribed medication to reduce his immediate anxiety and sent home with a friend, with instructions to return if his symptoms deteriorated. Piotr took his own life the next morning before he could be returned to hospital. Had a bed been available and Piotr had been admitted as he and medical staff had wished on the evening of the 16th December 2019, his death would not have occurred. I am therefore concerned in relation to the overall bed capacity for those patients like Piotr seeking informal admission. In addition, I am concerned about the provisions to temporarily house a patient wishing informal admission in the circumstances that a bed is not immediately available. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8th December 2020 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. 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;- 1. Piotr’s next of kin. 2. Chief Executive of the Norfolk and Suffolk NHS Foundation Trust I am 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 12th October 2020 Nigel Parsley
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.
From Nadine Dorries MP
Minister of State for Patient Safety,
Suicide Prevention and Mental Health
39 Victoria Street
London
SW1H 0EU
020 7210 4850
16 December 2020
Mr Nigel Parsley
HM Senior Coroner, Suffolk
HM Coroner's Office
Beacon House
53-65 Whitehouse Road
Ipswich IP1 5PB
Dear Mr Parsley,
Thank you for your letter of 12 October to Matt Hancock about the death of Piotr
Kierzkowski. I am replying as Minister with responsibility for mental health and suicide
prevention and I am grateful for the additional time in which to do so.
I was saddened to learn of the circumstances of Mr Kierzkowski’s death and wish to offer
my sincere condolences to his family and loved ones. We must do all we can to take the
learnings from Mr Kierzkowski’s death to improve the safety of NHS care for others.
Your report raises matters of concern relating to the availability of mental health beds for
patients who require informal admission to hospital in a crisis; and alternative provision
where an inpatient bed is not immediately available.
In preparing this response, my officials have made enquiries with NHS England and NHS
Improvement (NHSE/I) to understand the action taken locally to improve the provision of
mental health emergency care.
Local bed capacity and crisis care
I am advised by NHSE/I that the Norfolk and Suffolk NHS Foundation Trust has increased
capacity through the opening of four crisis house beds in Norwich, with plans to open two
additional crisis houses in the coming months, as well as extra ward capacity for older
people. This is expected to significantly enhance local bed capacity.
I am further advised that the Trust has reviewed its bed management processes to ensure
they facilitate clinically-led admissions; make use of every available alternative to out of
area placements; and support safe discharge. In line with national policy, I am assured
that the Trust is developing its community mental health services so that safe and effective
care can be provided as close to home as possible.
I am encouraged by these developments locally. However, it is important that the Trust
and local commissioners ensure that they reflect carefully on the circumstances of Mr
Kierzkowski’s death and identify any opportunities for further learning. To support learning
at a national level, my officials have brought your report to the attention of the Care Quality
Commission (CQC), as the independent regulator of quality, and NHSE/I, as system
leader of NHS-funded care.
National improvements to mental health provision
At a national level, I would like to assure you that the overarching aim of the NHS Long
Term Plan1 ambitions and new investment in mental health services, is to ensure that
people can access the appropriate service for their needs in a timely way, preventing
further deterioration and allowing the least restrictive care. This means caring for people
outside hospital where it is safe to do so, but ensuring that when admission is required, it
can be arranged immediately and as close to home as possible.
There are a number of key commitments that support this aim, most notably the national
policy to end reliance on adult acute out of area placements by April 2021. This
commitment aims to ensure that all local mental health systems are operating effectively,
with sufficient local bed capacity so that everyone can be admitted close to home and at
the right time.
However, patient safety is the first priority and NHSE/I, as system leader, is clear that if an
urgent admission is required and a local bed is not available, mental health providers
should seek and secure a placement out of area. You may wish to note that it is not the
case that detention under the Mental Health Act is required to access a bed quickly.
National and regional support has been provided to mental health services working to
reduce out of area placements, with a particular focus on those areas that have been the
most challenged. This includes clinically-led, bespoke improvement support and ensuring
that strategies are in place to invest in community services and alternatives to admission.
To deliver early and effective intervention for people in mental health crisis, the NHS Long
Term Plan focuses on:
• Transforming and expanding community mental health services for adults and older
adults with severe mental illnesses. By the end of 2023/24 every local health
system will have at least one new community service model in place, giving patients
greater choice and control over their care, and supporting them to live well in their
communities; and,
• Delivering 100 per cent coverage of 24/7, age-appropriate crisis care, via NHS 111,
by 2023/24.
In recognition of the additional service pressures this winter resulting from the COVID-19
pandemic, an additional £50million is being provided to deliver strengthened support for
mental health patients following their discharge from inpatient care over the coming
months. This will be used to ensure that patients who are ready to leave inpatient facilities
1 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
have the community support they need and will improve the availability of inpatient care for
those who require it.
Suicide prevention
I would also like to explain the important work being taken forward on suicide prevention.
In 2018, we launched a zero-suicide ambition for mental health inpatients which means
that every mental health NHS trust now has a zero-suicide ambition plan in place.
In January 2019, we published the first Cross-Government Suicide Prevention Workplan2,
which sets out an ambitious programme across national and local government and the
NHS and will see every local authority, mental health trust and prison in the country
implementing suicide prevention policies.
I am pleased to say that every local authority now has a multi-agency suicide prevention
plan in place and we are working with local government, including investing almost
£600,000 to assure the effectiveness of those plans.
We have made further investment of £1.8 million to support the Samaritans helpline and
£2 million for the Zero Suicide Alliance, which aims to achieve zero suicides across the
NHS and in local communities by improved suicide awareness and prevention training and
developing a better culture of learning from deaths by suicide across the NHS.
From 2019/20, the Government has been investing £57 million in suicide prevention
through the NHS Long Term Plan. This will see investment in all areas of the country by
2023/24 to support local suicide prevention plans and establish suicide bereavement
support services. We have ensured that the suicide prevention funding for local areas
includes addressing self-harm as a priority focus.
The NHS Long Term Plan also commits to developing integrated models of primary and
community care to support people with complex needs, including self-harming.
In addition, we have:
•
Invested £249 million to ensure every Accident and Emergency department has a
mental health liaison team in place by 2020/21; and
• Committed to ensuring that 70 percent of liaison mental health teams meet the 24
hours a day, seven days a week standard by 2023/24 and 100 percent thereafter, in
the NHS Long Term Plan.
Commenting on the wider aspects of your report, you may wish to note that in 2018, the
Healthcare Safety Investigation Branch (HSIB) undertook an investigation and produced a
report Provision of mental health care to patients presenting at the emergency department
for wider learning within the NHS. HSIB’s report reinforced the need for improved access
to emergency mental health care and made four safety recommendations.
2
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/772210/national
-suicide-prevention-strategy-workplan.pdf
A summary of responses to the recommendations is available online3.
As already outlined, NHSE/I is working to expand the provision of urgent and emergency
liaison mental health services across England in line with commitments made in the NHS
Long Term Plan. This includes expanding the provision of services for people experiencing
a mental health crisis and increasing alternative forms of provision.
In addition, the CQC has made changes to its assessment of the quality and safety of care
in its inspections of acute hospitals. This includes that mental health inspectors now
routinely participate as part of the inspection team, and there are new key lines of enquiry
focused on mental health provision in its inspection framework.
You may wish to note that in October 2020, the CQC published a report on the
Assessment of Mental Health Services in Acute Trusts (AMSAT) that highlighted issues
around access to and provision of mental health services in acute trusts, including in
Emergency Department (A&E) settings. While CQC found some progress, it identified that
there is a need for improvement across AMSAT mental health provision and for better
access to mental health care and support.
CQC’s AMSAT report found that while staff were working hard in difficult circumstances,
the system often limited their ability to provide the best possible mental health care to
patients. CQC recommended steps that providers, clinical commissioning groups and local
authorities can take to improve the quality of care for patients.
In summary, this Government is committed to improving mental health provision across
the country and there is a particular focus on suicide prevention in the NHS Long Term
Plan for Mental Health, which includes improving access to emergency mental health care
for those who need it.
I hope this response is helpful. I am grateful to you for bringing these concerns to my
attention.
Yours sincerely,
MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH
NADINE DORRIES
3 https://www.hsib.org.uk/investigations-cases/provision-mental-health-services-emergency-departments/
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