Prevention of Future Deaths reports
Regulation 28 report to prevent future deaths, reference 2020-0300. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Reference | 2020-0300 |
|---|---|
| Deceased | James Taylor |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Community health care · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MISS N PERSAUD SENIOR CORONER EAST LONDON Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Head of Continuing Care, Redbridge Clinical Commissioning Group, 6th Floor, North House, St Edwards Way, Romford RM1 3AE Email: 1 CORONER I am Nadia Persaud, senior coroner, for the coroner area of East London 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 12th November 2019 I commenced an investigation into the death of James Alexander David Taylor, 35 years old. The investigation concluded at the end of the inquest on 11th December 2020. The conclusion of the inquest was a narrative conclusion: Mr Taylor died as a result of suicide. He took his own life following life changing injuries sustained during a road traffic collision. The injuries sustained in the collision caused a functional neurological disorder manifesting in refractory pain and sensory disturbances. These, in turn, led to psychological distress and suicidal ideation. Mr Taylor sought help for his pain and psychological distress. Long-term psychological therapy was required. The required help was not provided to him. In August 2019, Mr Taylor attended a long awaited multi-disciplinary programme for functional neurological disorder. He had 1 attended preparatory sessions for the in-patient programme, to determine his suitability. The extent of his pain was not explored at the preparatory sessions and his engagement in the programme was terminated after 4 days, due to pain limiting his engagement. It is clear from communication left by Mr Taylor that the feeling of rejection from this programme contributed to his decision to take his own life. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death can be seen from the narrative conclusion set out in section 3, above. In relation to psychological therapies, Mr Taylor underwent twenty sessions of individual psychotherapy in 2016. These were provided by the Redbridge Psychological Services. Mr Taylor was noted to have complex and severe mental health problems. The psychologist considered that Mr Taylor would need a longer term of psychological therapy, however twenty sessions was all that could be offered under the limits of the Redbridge service. The psychologist stated that in order for James to recover, he would require a minimum of a year of further sessions. As well as the psychologist specifying this need, James made further requests to the mental health trust, for the provision of further psychological therapy. The required therapy was never provided to him. 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 could 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 Inquest heard evidence that psychological therapy within Redbridge is provided on a limited basis. The Inquest heard that a maximum of twenty sessions would be provided and must be stopped when that number is reached. This is so, even where the patient requires ongoing psychotherapy. 2. The Inquest heard that psychotherapy can bring to the surface a number of distressing and traumatic events. If the therapy has not reached a therapeutic conclusion, then patients can be left with unresolved distress and trauma. 3. As well as the arbitrary cut-off for psychological therapies, the Inquest also heard that there can be extreme delays (of up to 9-10 months) for patients to receive the psychological therapy required. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that 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 15th February 2021 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Taylor, the CQC. I have also sent it to the Director of Public Health who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 21/12/2020 SIGNED BY CORONER 3 MISS N PERSAUD SENIOR CORONER EAST LONDON Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dr , Senior Officer, Royal College of General Practitioners, 30 Euston Square, London NW1 2FB Email: 1 CORONER I am Nadia Persaud, senior coroner, for the coroner area of East London 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 12th November 2020 I commenced an investigation into the death of James Alexander David Taylor, 35 years old. The investigation concluded at the end of the inquest on 11th December 2020. The conclusion of the inquest was a narrative conclusion: Mr Taylor died as a result of suicide. He took his own life following life changing injuries sustained during a road traffic collision. The injuries sustained in the collision caused a functional neurological disorder manifesting in refractory pain and sensory disturbances. These, in turn, led to psychological distress and suicidal ideation. Mr Taylor sought help for his pain and psychological distress. Long-term psychological therapy was required. The required help was not provided to him. In August 2019, Mr Taylor attended a long awaited multi-disciplinary programme for functional neurological disorder. He had 1 attended preparatory sessions for the in-patient programme, to determine his suitability. The extent of his pain was not explored at the preparatory sessions and his engagement in the programme was terminated after 4 days, due to pain limiting his engagement. It is clear from communication left by Mr Taylor that the feeling of rejection from this programme contributed to his decision to take his own life. 4 CIRCUMSTANCES OF THE DEATH The immediate circumstances of the death can be seen from the narrative conclusion set out above. In relation to the primary health care provided to Mr Taylor, concerns were raised by his family and friends in relation to the number of different general practitioner surgeries involved in his care and the lack of continuity of care. Evidence was heard from his final GP, who confirmed that Mr Taylor had a very large volume of medical records due to his complex physical and mental health needs. The practice received an electronic transfer of records. There was no transfer letter or clear summary of his ongoing clinical needs. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – As a result of his complex health needs, Mr Taylor changed address on a number of occasions. This required a number of changes of general practitioner surgeries. In 4 years, Mr Taylor had changed surgeries 4 times. The Inquest heard evidence from his final general practitioner who confirmed that there was a large volume of records relating to Mr Taylor. The GP confirmed that no summary of care is provided to GP practices when transfer of patients take place. He confirmed the dangers of this, in that important clinical matters can be missed where a patient has a large volume of records. The general practitioner indicated that handover summaries should be provided to GPs when complex patients are transferred from surgery to surgery. Such transfer summaries could include a summary of past medical history and highlight acute, ongoing clinical conditions, together with any safeguards around prescribing of medication. Such summaries could ensure safety in the continuity of care 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 18 February 2021 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family of Mr Taylor. I have also sent it to the Director of Public Health, the CQC and the Liberty Road Bridge Practice, who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 23/12/2020 SIGNED BY CORONER 3
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.
Your ref:
12 February 2021
Miss Nadia Persaud
Senior Coroner East London
Walthamstow Coroner’s Court
By email to:
Dear Miss Persaud
6th floor, North House
St Edwards Way
Romford
RM1 3AE
Tel:
Re:
Inquest touching upon the death of Mr James Alexander David Taylor,
Regulation 28 Report
I write in response to the Prevention of Future Deaths Report issued to Redbridge Clinical
Commissioning Group on the 21 December 2020, following the Coroner’s inquest into the
death of Mr James Alexander David Taylor.
The CCG commissioning lead and NELFT heads of service have met to discuss the Coroner’s
concerns set out in the Regulation 28 report and agreed actions to prevent future deaths.
Some changes to the standard operation procedure for the Psychological Therapies service
were implemented in 2018, which address some of the concerns of the Coroner and further
actions have been agreed to reduce the risk of a similar incident occurring again.
Please find attached a report for the Coroner on the actions that have been taken.
The CCG strives to learn from incidents and to constantly improve the service provision it
provides. Please do not hesitate to contact me if you require any clarification.
Thank you for your helpful insights into this case.
Yours sincerely
Managing Director
cc:
Director of Public Health, London Borough of Redbridge
Attachment: REGULATION 28: Report to Prevent Future Deaths from Nadia Persaud, Senior
Coroner East London, 21.12.20.
Accountable Officer:
Managing Director:
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups
Chairs:
Dr
Dr
Dr
, Barking and Dagenham Clinical Commissioning Group
l, Havering Clinical Commissioning Group
, Redbridge Clinical Commissioning Group
Response to: REGULATION 28: Report to Prevent Future Deaths from
Nadia Persaud, Senior Coroner East London, 21.12.20.
From:
, Managing Director, BHR CCGS
Date: 12 February 2021
1. This report provides a response to the Report to Future Prevent Deaths from
Nadia Persaud, Senior Coroner East London, of 21.12.20.
2. Barking and Dagenham, Havering and Redbridge CCGs have reviewed the
Coroner’s concerns in the report relating to the death of James Alexander David
Taylor. Mr Taylor was under the care of the North East Mental Health Trust
(NELFT) for the management of his mental health problems and the CCG has
discussed the concerns raised by the Coroner with NELFT in order to respond to
the issues raised.
3. NELFT have confirmed that Mr Taylor was under the care of the Psychological
Therapies team and not the Psychotherapy Team. We can confirm that NELFT
provide both Psychological Therapy services and they also have a small
Psychotherapy service.
4.
In 2016, the Psychological Therapies team would have offered 20 sessions per
referral. Patients would have been reviewed at week 17 and if it was indicated,
potentially offered more sessions. However, it is acknowledged that the access
may have be limited due to the high demand for the service at the time.
5. At the time that Mr Taylor was receiving services from NELFT, approximately
four years ago, there may have been a waiting list of up to one year. There is no
national wait time standard for psychological therapy in secondary care, and a
local standard has not been implemented locally. The National Audit of Anxiety
and Depression (NCAAD) reports that almost half of adults wait more than 18
weeks from referral to treatment 1.
6. Some actions have already been taken to improve access to the Psychological
Therapies service and ensure that sessions are tailored to an individual’s clinical
need:
6.1 In 2018, NELFT implemented a standard operating procedure (SOP) for
Psychological Therapy services which outlines the processes for safely
managing patients on wait lists and also for safe discharge from the
service. The SOP states that “Interventions will routinely be offered for 20
sessions. Each pathway should have a system for reviewing plans to
extend the number of sessions.” Following the agreement of the SOP in
April 2018 a patient can be offered more sessions following a review,
based on clinical need not demand.
1 How are secondary care psychological therapy services for adults with anxiety and
depression performing? Results of an audit of NHS-funded services in England:
a co-produced report. Healthcare Quality Improvement Partnership (HQIP) 2020.
1
6.2 Over the past two years some additional capacity has been brought into
the service, facilitated by additional investment in 2017/18. There is
increased integrated working between the psychology service and
multidisciplinary teams, through the development of integrated posts into
Access and Assessment teams.
6.3 NELFT have reviewed and updated the panel protocol to ensure
involvement of all relevant services, including Access and Assessment.
Teams, in the process and to routinely manage risks associated with
long waits. The current average waiting time for the Mood, Anxiety and
Personality pathway in Redbridge is six months. To manage risks whilst
individuals are on a waiting list, the team will:
➢ Risk assess individuals and crisis plan at the assessment stage
➢ Offer low intensity therapy where appropriate
➢ Offer group sessions where appropriate
➢ Maintain regular contact, including clinical harm reviews
➢ Prioritise some groups for assessment and or treatment CAMHs
transitions, high risk.
6.4 NELFT has a structure of Trust wide clinical leadership for secondary care
services to ensure we have robust supervision arrangements in place to
support the delivery of NICE recommended treatments.
6.5 NELFT routinely review wait times and identify gap which feed into
commissioning discussions.
7. BHR CCG and NELFT have agreed the following additional actions to avoid
future deaths:
• NELFT will formally review their services in line with the NCAAD report
recommendations by the end of May 21
• The CCG is considering a proposal for additional investment into
psychological services in 21/22. This will further improve on the waits for
treatment and will improve the offer of broader psychological support within
NELFT services
8. Please note that the report has been copied to
Health for London Borough of Redbridge.
, Director of Public
2
Ms Nadia Persaud Her Majesty's Coroner - East London Sent cl 13 January 2021 Dear Ms Persaud, Re: Inquest touching upon the death of James David Alexander Taylor - Regulation 28 (Preventing Future Deaths) report Thank you for your letter of 23 Dec 2020 regarding the death of Mr Taylor. Please pass on my condolences to his family and friends. | am replying as Joint Honorary Secretary of the Royal College of General Practitioners. The Royal College of General Practitioners (RCGP) is the largest membership organisation in the United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of general medical practice and to act as the ‘voice’ of GPs on issues concerned with education; training; research; and clinical standards. Founded in 1952, the RCGP has just over 54,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. From your letter, it would appear that Mr Taylor had a number of complex problems, particularly following a road traffic collision. It is also clear that Mr Taylor changed GP surgeries on four occasions prior to unfortunately taking his own life. | understand that the question you have posed is regarding the structure of the GP records that are transferred from one surgery to another and specifically with regard to a summary problem list and medication. In responding to this question, it is worth noting that general practice in the UK is the most computerised element of the health service and has been so for many years. It is now very rare that handwritten notes are made and GPs rely upon specialist computer systems to record and transfer records, as patients move from one surgery to another. The standards and approaches are governed by NHS England and NHS Digital but in summary they include not just the content but also the structure of record keeping. There are a number of GP IT suppliers but the largest is EMIS, which supports the majority of GP surgeries in England. Within the computer programmes, they automatically populate a current and/or significant problem list and secondly an inactive problem list. Examples Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Patron: HRH The Duke of Edinburgh | Registered Charity Number 223106 of the former might be a serious health problem such as heart attack or significant mental health difficulty and for the latter, a more routine problem such as a chest infection which would initially be in the current problem list and then move onto the inactive list after a period of time. They also automatically document immediate and repeat prescriptions. In terms of notes moving from one practice to another, almost always this is a “pull system" whereby it is registration of the patient at their new chosen surgery that starts a process of the previous medical notes being transferred. Whilst in a small number of occasions, a patient may indicate that they are moving to another surgery and give an opportunity for the “leaving” practice to have a clinical handover to the “receiving" practice, this is relatively rare; although when there are complex problems it can be helpful. Increasingly, although not universally, upon registration, medical records are transferred electronically using a system called GP2GP electronic transfer. See details bere, which is run by Primary Care Support England. This has the important set of advantages that the whole record is transferred across and usually seamlessly. This would include any active problem lists, medications and other details. It is also much quicker. However, paper transfer is also used - this still requires that the “leaving” surgery print out the full medical record and the “receiving” surgery to then go through the record, scan it and act upon any obvious issues. There are clearly potential timing and resource risks with this latter process. | have attached the necessary guidance from Primary Care Support Services for your information. The responsibility for the system of transferring records lies with Primary Care Support England rather than RCGP, but our position is to support electronic transfer for the reasons articulated above. | trust that this reply is helpful and if you have any questions, please do not hesitate to contact me. Yours sincerely,
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