Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0037, written 11 Feb 2021. 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 2021 |
|---|---|
| Reference | 2021-0037 |
| Deceased | Carole Mitchell |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Mental Health related deaths · Suicide (from 2015) · Alcohol, drug and medication related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Department of Health and Greater Manchester Health and Social Care Partnership 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 INVESTIGATION and INQUEST 3 On 25th November 2019 I commenced an investigation into the death of Carole Mitchell. The investigation concluded on the 3rd February 2021 and the conclusion was one of suicide. The medical cause of death was 1a) Diltiazem toxicity on background of hypertensive heart disease 4 CIRCUMSTANCES OF THE DEATH Carole Mitchell had a long history of involvement with mental health services, including being sectioned under the Mental Health Act and periods of voluntary admission at mental health units. Between 2017 and 2019, she was an inpatient on six occasions. She had three reported attempts to take her own life between 2017 and 2019. Throughout her time with Mental Health Services, she was reluctant to have information shared with her family. Her family were concerned about her deterioration. In 2019 however attempts by them to share information were not actively pursued by Mental Health Services and as a result information gathering that would have assisted in assessing her was limited. She was transferred from the Home-Based Treatment Team (HBTT) to the Community Mental Health Team (CMHT) on 1 18th April 2019. There was a clear conflict in the understanding between the two teams regarding her care plan at handover, which was not recognised by either team. Following transfer to the care of the CMHT, she was seen less often. This was not fully detailed, or risk assessed. On 29th April 2019, it was decided Carole Mitchell would benefit from psychological assessment and she was added to the Secondary Care Psychology waiting list. The first appointment was 21st November 2019. The delay was due to a lack of appointments for that service. It was identified she would benefit from a support worker to work alongside the care co-ordinator. The first support worker's relationship was unsuccessful, and a decision was taken she should be replaced. There was a three month wait for a replacement support worker. There was no formal escalation to seek to prioritise Carole Mitchell, although it was clear the support service would be beneficial to helping her with her mental health. On 8th October 2019, her husband told mental health services that she had attempted to take an overdose on 6th October 2019. Following that disclosure, her case was not red zoned by her care co-ordinator and there was no face to face assessment to identify if any additional strategies would assist in supporting her or reducing risk. On 22nd November 2019, her husband left home at about , Sale at 6:45am. He returned home to about 6:15pm. He found Carole Mitchell unresponsive on the floor in the main bedroom. Police enquiries found no suspicious circumstances or evidence of third-party involvement in her death. There was no note or message found. Her medication was found by her bedside. Post-mortem examination, including toxicology, found that she had died from a fatal amount of her prescribed medication. 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. 2 The MATTERS OF CONCERN are as follows. – 1. The inquest heard that psychology assessment and therapies can be very beneficial to those with mental health issues in secondary services as well as primary services. The evidence given was that the delay that Mrs Mitchell experienced in accessing that service was reflective of both the regional and national backlog for appointments. The inquest was told that the position had worsened since 2019 and for example someone in Mrs Mitchell’s position today would be more likely to wait 9 months than the 7 months in 2019. 2. Mrs Mitchell on two occasions could not be accommodated locally when an inpatient stay was required. The evidence heard at the inquest was that this was due to limited national mental health bed capacity against the demand within mental health services. The inquest heard evidence that suggested that this impacted on how she could be supported by her family and overall care. 3. It was accepted at the inquest that information gathering from family could be beneficial. However, there was a reluctance by health professionals to fully utilise information gathering due to concerns about breaching patient confidentiality. This appeared to stem from a misunderstanding between the concept of information sharing and information gathering and how they inter related with the principle of patient confidentiality. 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 8th April 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. 3 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the , the following Interested Persons namely husband of Carole Mitchell and Greater Manchester Mental Health, who may find it useful or of interest. 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 Alison Mutch HM Senior Coroner for the Coroner Area of Greater Manchester South 11/02/2021 4
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.
From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H 0EU 28 April 2021 Ms Alison Mutch HM Senior Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Thank you for your letter of 11 February 2021 about the death of Carole Mitchell. I am replying as Minister with responsibility for mental health services and I am grateful for the additional time in which to do so. I would like to begin by expressing my deepest sympathies to the family and loved ones of Carole Mitchell. I was greatly saddened to read of the circumstances of Mrs Mitchell’s death. Your report raises important concerns regarding access to psychological therapies in secondary mental health services; inpatient bed capacity; and, information sharing between mental health professionals and families. I am aware that the Greater Manchester Health and Social Care Partnership has provided a detailed response on the actions that are being taken locally to improve access to services and to encourage and strengthen family involvement in care where appropriate. My response will focus on the actions taken at national level. Reducing suicide and preventing self-harm remains a priority for this Government. As part of the £2.3billion settlement for mental health in the Long Term Plan, we are providing targeted and ring-fenced funding to local areas so they can deliver their multi-agency plans. This includes suicide prevention activities, initiatives to prevent self-harm and putting in place postvention1 bereavement support. We have committed that every area of the country will receive funding specifically for suicide prevention and bereavement services by 2023/24, from the total pot of money of £57 million for suicide prevention. In relation to access for psychological assessments and therapies, the Government and the NHS are taking steps to ensuring that no one faces a long wait to access mental health support. 1 Intervention after a suicide. As mentioned, under the NHS Long Term Plan, mental health will receive a growing share of the NHS budget, worth in real terms at least a further £2.3 billion a year by 2023/24. The NHS Long Term Plan has committed to the implementation of new integrated models of primary and community mental health care that improve care for adults with a range of severe mental health problems, in all local areas in England by 2023/24, backed by almost £1billion extra. This will give an additional 370,000 more adults access to better support for severe mental illness by 2023/24. The NHS Long Term Plan makes clear that the provision of the National Institute for Health and Care Excellence (NICE) recommended psychological therapies is critical to ensure that adults with severe mental illness can access evidence-based care and experience improved outcomes. However, we know there is regional variation in current provision, in part due to the pressures facing some parts of our community mental health workforce over recent years. To address this, since 2018/19, NHS England has invested in the commissioning of training places for community mental health staff to go on courses in psychological therapies for people with severe mental illness, in partnership with Health Education England. We will continue to commission new training places each year up to at least 2023/24 to increase competency within the workforce. Turning to your second matter of concern regarding the availability of inpatient beds, the Five Year Forward View for Mental Health2, set out the commitment to eliminate inappropriate adult Out of Area Placements (OAPs) by the end of 2020/21, recognising their negative impact on the quality of care and of being disconnected from family, friends and support networks. Prior to the outbreak of COVID-19, good progress was being made towards this target nationally. However, COVID-19 has made the already stretching ambition even more challenging, due to consistently high capacity pressures resulting from the negative impact of the pandemic on mental health need; reduced bed capacity in some areas due to infection prevention and control requirements; interruptions to usual support structures and access to community services; and delayed progress in delivering planned pathway improvements while focussing on the COVID-19 response. Despite this, reliance on OAPs remains highly variable and has already been significantly reduced or eliminated in a number of areas. The expected enduring impact of the pandemic is likely to mean that the increased need for mental health care and treatment is sustained in the medium term. We are still working to deliver the ambition to eliminate OAPs by April 2021 in those systems where it is feasible. However, patient safety will not be compromised in pursuit of delivering the national ambition. All systems that still have OAPs beyond March 2021, will be required to commit to a new target in light of their specific local challenges, to ensure OAPs are eliminated everywhere as soon as reasonably possible. 2 The Five Year Forward View for Mental Health (england.nhs.uk) In addition to transforming and expanding community mental health services, we are ensuring discharge is well-planned and effective, so that people are not in hospital for any longer than they need to be. We have recently announced that £87million will be used to support good quality discharge from mental health facilities. This is part of the additional £500 million mental health recovery plan3 announced to address waiting times for mental health services, give more people the mental health support they need, and invest in the NHS workforce. Finally, in relation to the third matter of concern in your report and information sharing, the Department of Health and Social Care, with input from leading mental health organisations, developed an Information sharing and suicide prevention consensus statement4, to help address the concerns families have regarding mental health practitioners being reluctant to take information from families or to divulge information about a person’s suicide risk. Through its contract with the Department, the Zero Suicide Alliance is developing guidance for frontline staff on how to use the Consensus Statement and when and how to share information to help prevent suicide. Development of this resource is ongoing, with the guidance due to be published shortly. We will continue to promote this statement through our networks. In addition, the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) has developed a resource on Safer services: A toolkit for specialist mental health services and primary care5, which includes guidance regarding family involvement. This is part of our broader work to support local areas in their quality improvement plans for suicide prevention. I hope this reply is helpful. Thank you for bringing your concerns to my attention. NADINE DORRIES MINISTER OF STATE FOR PATIENT SAFETY, MENTAL HEALTH AND SUICIDE PREVENTION 3 COVID-19 mental health and wellbeing recovery action plan (publishing.service.gov.uk) 4 Information sharing and suicide prevention: consensus statement (publishing.service.gov.uk) 5 display.aspx (manchester.ac.uk)
Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN Date: 8th April 2021 Ms A Mutch OBE HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Re: Regulation 28 Report to Prevent Future Deaths – Carole Mitchell 25.11.2019 Thank you for your Regulation 28 Report dated 11 February 2021 concerning the sad death of Carole Mitchell on 11 November 2019. Firstly, I would like to express my deep condolences to Carole Mitchell’s family. The inquest concluded that Carole’s death was a result of 1a) Dilitiazem toxicity on background of hypertensive heart disease. Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken. This letter addresses the issues that fall within the remit of GMHSCP and how we can share the learning from this case. The Greater Manchester mental health system is cognisant of the capacity issue across the different routes into accessing psychological therapy into Community Mental Health Teams (CMHTs). This is an issue that is prevalent across the country as fundamentally there are not sufficient levels of availability required in respect to assessments/appointments based on the exponential growth in demand we have seen year on year. For example, there are certain services that may have 350 service users/patients under it, but only one full time equivalent clinical psychologist providing the required psychology assessments and therapies. Due to this there is a ‘stepped care’ or ‘capacity’ model in order to effectively spread the limited resource available within the system. To manage this inequity between capacity and demand, the Mental Health Trusts in GM employ the strategy of daily meetings of multidisciplinary teams to assess, prioritise and deploy the resource available based on the need of service users/patients. There is both local and national (NHSE/I) acknowledgement that this is one of the most significant challenges we face in mental health. The NHS Long Term Plan has identified a number of strategies by which we both upskill the current workforce and increase the size of the workforce. In GM we are in the process of developing a bespoke workforce strategy/plan that will ensure we see a significant surge in new recruits into mental health services which we believe will pointedly reduce the current waiting time for services. Prior to the Covid-19 pandemic, there had been a significant reduction (66% over a two-year period) in Out of Area Placements (OAP) for GM patients. However, over the last 12 months there has been a significant rise in OAP due to the significant spike in demand for services. As a consequence, we have mobilised a number of initiatives to ensure that GM patients are, in the main, treated locally: - Delayed Transfer of Care programme (DTOC) – significant monies (£2.8m) has been recently invested with both NHS and Voluntary Community Social Enterprise (VCSE) organisations to reduce/eliminate bed blockage. This has enabled us to mobilise thirty-six schemes which has resulted in substantial reduction in DTOC which has had a direct impact in reducing our OAPs Independent Sector (IS) – in the last month NHSE in North West of England have secured a contractual agreement with all our IS MH secondary service providers to exclusively provide their beds for residents of North West of England. This will ensure that our patients, that cannot be accommodated within our NHS/VCSE facilities, will be accommodated within local IS facilities. - We are actively working with all partner organisations across Primary/ Community/ Secondary care to ensure that information on patients is routinely shared. We are conscious that this is critical to ensuring better and safer care for all our patients. As part of our mental health strategy 2021-24, we will look to enhance our digital capabilities to support this very important objective. Actions taken or being taken to prevent reoccurrence across Greater Manchester. 1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE. 2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice. I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely Chair of GM Medical Executive, GMHSCP
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