Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0109, written 15 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Apr 2021 |
|---|---|
| Reference | 2021-0109 |
| Deceased | Saima Hussain Mann |
| Coroner | Adrian Farrow |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Greater Manchester Mental Health NHS Foundation Trust 1 CORONER I am Adrian Farrow, assistant coroner, for the coroner area of 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. 3 INVESTIGATION and INQUEST On 12th August 2019 an investigation was commenced into the death of Saima Hussain – also known as Saima Hussain Mann, aged 40 years. The investigation concluded at the end of the inquest on 1st April 2021. The conclusion of the inquest was that she died of suicide by hanging. 4 CIRCUMSTANCES OF THE DEATH The inquest heard that Saima Hussain had a long history of mental disturbance. For the 12 months preceding her death on 10th August 2019, she had assistance from the Psychological Therapies Service, which concluded at the end of January 2019, followed by repeated episodes of crisis. She was an in-patient under s2 Mental Health Act 1983 at the beginning of April 2019 and again at the beginning of May 2019. There were a number of mental health assessments undertaken during this period, none of which identified any risk of harm to herself. The Community Mental Health and the Trafford Adult Social Care teams were both involved and she was the subject of discussion at multi-disciplinary and Daily Risk meetings. She had contact with her GP. Ms Hussain was assessed by a Clinical Psychiatrist, who concluded that she did not meet the criteria for assistance by the Community Mental Health Team and an informal referral was made back to the therapist at the Psychological Therapies Service who had assisted her previously. That informal referral was subsequently formalised. The inquest heard that Ms Hussain relied upon particular healthcare professionals in whom she had established confidence and trust. Once the referral had been accepted, there was no identifiable person who could be a point of contact for Ms Hussain. At the time of the handover from the Community Mental Health Team to the Psychological Therapies Service, the inquest heard that Ms Hussain told the social worker from the Community Mental Health Team that she felt “lost” and “abandoned”. The Psychological Therapies Services attempted to send an acknowledgement letter to Ms Hussain, which was returned undelivered. It was pro-forma in nature and gave no indication as to the likely course of events beyond the fact that she had been placed on a waiting list. There was no direct contact with Ms Hussain between her discharge from the Community Mental Health Team and her death to inform her of the plan for her future care and the evidence was that she experienced a further period of crisis which appears to have been triggered by the lack of contact and information surrounding her referral to the Psychological Therapies Services. Ms Hussain took her own life in early August 2019. 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 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. – The Trust had systems and procedures in place in relation to the referral by the Community Mental Health Team to the Psychological Therapies Services, but there did not appear to be in a place a reliable or established system which would ensure that the service-user would receive direct contact from the Trust, tailored to their particular situation and condition to ensure that they were fully informed as to the fact, status and plan for their referral. The acknowledgement letter which was intended to be delivered to Ms Hussain was a pro-forma which gave no indication as to what she should expect, beyond the information that she had been placed on a waiting list. It does not appear that the procedures in place take account of the likely needs of the service-users who are by definition, seeking assistance with mental illness. It is understood that the Community Transformation Project is currently in the process of reviewing the mental health service, but there is no timescale available over which the question of referrals will be considered. Pending that review, my concern is that the level and method of communication with those being referred to the service does not take account of their particular needs and may affect their mental health. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 10th June 2021. I, the coroner, may extend the period. 2 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: deceased). (family of deceased), and (family of 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 15th April 2021 Signature: Adrian Farrow, Assistant Coroner, Manchester South 3
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.
PRIVATE & CONFIDENTIAL HM Assistant Coroner Mr Adrian Farrow Manchester South Coroner’s Office 1 Mount Tabor Street Stockport SK1 3AG 8th June 2021 Dear Mr Farrow Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL Web: www.gmmh.nhs.uk Re: Saima Hussain (deceased) Regulation 28 Preventing Future Deaths Response Thank you for highlighting your concerns during Ms Hussain’s Inquest and please see the Trust’s response in relation to these concerns below. Your MATTERS OF CONCERN were as follows: The Trust had systems and procedures in place in relation to the referral by the Community Mental Health Team to the Psychological Therapies services but there did not appear to be in a place a reliable or established system which would ensure that the service user would receive direct contact from the Trust tailored to their particular situation and condition to ensure that they were fully informed as to the fact, status and plan for their referral. The acknowledgement letter which was intended to be delivered to Ms Hussain was a proforma which gave no indication as to what she should expect, beyond the information that she had been placed on the waiting list. It does not appear that the procedures in place take account of the likely needs of the service users who are, by definition, seeking assistance with mental illness. It is understood that the Community Transformation Project is currently in the process of reviewing the mental health service, but there is no timescale available over which the question of referrals will be considered. Pending that review, my concern is that the level and method of communication with those being referred to the service does not take account of their particular needs and may affect their mental health. As part of the referral process in place across the Trust Psychological Therapies Services there is a formal process of triage through the first point of contact which means that there should be direct contact with service users from the service following referral. In Ms Hussain’s case an informal process was adopted for referral between with good intention, unfortunately the formal process for referral was not adopted which meant that she did not receive a telephone call and was not updated regarding the process and timescales. Ms Hussain had previously said that she wanted to engage with the service, but only with the therapist she had previously seen. This was facilitated through the informal discussion between The service did send a letter to Ms Hussain’s address stating that she was on the waiting list for therapy, the letter was returned ‘undeliverable’ due to her letterbox being sealed. The Psychological Therapies Service Standard Operating Procedure (SOP) is clear about how referral should be managed. Following the return of the letter the SOP states that this should have been escalated to a clinical member of staff who would assess any risks and consider how the service would be able to best communicate with Ms Hussain. We are sorry that this did not happen on this occasion and administration staff did not escalate the return of the letter to clinical staff or telephone Ms Hussain due to their previous experience of her being hostile. To address this the manager of the service has made it clear to all staff the process regarding referral and the need for this to be adhered to as well as ensuring that all administration staff have received bespoke training from the Trust in relation to dealing with challenging communication on the telephone. The Trust want to assure you that Community Transformation Project will address referrals between services and how service users are kept informed of the reason for and progress of any referrals. In the interim the Trafford Service Manager is updating the CMHT Standard Operating Procedure (SOP) to include the process of discharge from the CMHT’s to ensure that referrals into other services are actioned / agreed before the case is discharged and closed to the CMHT’s and that this information is contained in the discharge letter from the CMHT and made available to the service user. This will be completed by 9th July 2021. The launching of the revised CMHT SOP by the end of July 2021 will further raise awareness within the team clinicians of the component parts of the service which relate to the timing of communication. The Community Service Manager will lead on promoting and implementing this. This will be achieved through face-to-face communication within individual supervision, team Business Meetings and team and leadership development sessions. This will be monitored by the Trafford division Senior Leadership Team (SLT) and completed by the end of August 2021. Through ongoing audit, our services and the wider Trust will monitor adherence to practice standards within Trafford CMHT services. The teams will carry out quarterly audits of CMHT discharges to give assurance to the Trust that this is being adhered to for 12 months following the SOP being completed and communicated to the CMHT staff. This will be led by the Team Manager in collaboration with CMHT administrators and the action plan monitored via the Trafford SLT and reported back to the PIR panel for executive oversight. I hope this response demonstrates that GMMH have taken the concerns you have raised seriously. If you have any further questions in relation to the Trust’s response please do let me know. Yours Sincerely, Dr Medical Director GMC
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