Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0116, written 21 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 | 21 Apr 2021 |
|---|---|
| Reference | 2021-0116 |
| Deceased | Susan Adams |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS = bf} CORONER J THIS REPORT IS BEING SENT TO: 1. PE victana Partnership NHS Foundation Trust, Chief Xecutive, Trust Headquarters, St George’s Hospital, Corporation Street, Stafford, ST16 3SR lam Mr Andrew Haigh Senior Coroner for the Coroner area of Staffordshire South 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 On 30" of December 2020 | commenced an investigation into the death of Susan Janet ADAMS. The investigation concluded at the end of the inquest on 20th April 2021. The conclusion of the inquest was ‘alcohol related’ with the cause of death being Combined toxicity of ethanol, pregabalin and fentany! with hepatic cirrhosis and steatosis. : CIRCUMSTANCES OF THE DEATH In 1989 while working as a Police Officer Susan Adams was severely assaulted and she never fully recovered from this. She suffered pain and developed a problem with her mental health and excess alcohol consumption. On 4th November 2020 5 | CORONER'S CONCERNS During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows: Mrs Adams and her family lived in couid be relevant for others who live close to county boundaries. | wonder if anything can be done to facilitate arrangements for secondary psychiatric care in these circumstances. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. 7TYOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10" June 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. — 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons EE and to rs: Pear Tree Surgery. - ! 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 | 21% April 2021 Andrew A Haigh ewer. A bene I. Cece eee eee sae eee eeeaeeasa tea eestnaetens HM Senior Coroner Staffordshire (South) Coroner’s Office No 1 Staffordshire Place Stafford $T16 2LP Tel No: 01785 276127 CC Lt
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.
F.!7:bj Midlands Partnership NHS Foundation Trust A Keele University Teaching Trust Chief Executive Trust Headquarters St George's Hospital Corporation Street Stafford ST16 3SR Mr A Haigh HM Senior Coroner for Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP 1st June 2021 Dear Mr Haigh, RE: Susan Janet ADAMS Regulation 28 Report to Prevent Future Deaths Thank you for your letter dated 21 st April March 2021, reporting a matter to us, in accordance with Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. May I take this opportunity to reassure you that following Mrs Adams death, we undertook a thorough investigation into the care delivered by the Midlands Partnership Foundation Trust. MATTER OF CONCERN: Mrs Adams and her family lived in Dosthi/1, Tamworth, Staffordshire. I was told that this was approximately 50 feet from the border with Warwickshire (and not far from West Midlands as well) and that her GP Practice was in Kingsbury Warwickshire. She needed regular psychiatric assistances from secondary mental health services and I was advised there were significant commissioning difficulties with this because of the home address and GP Practice being in different counties. Mrs Adams could access the crisis team in Staffordshire but long term treatment was supposedly to be provided in Warwickshire. This may have impacted on the care that Mrs Adams received and could be relevant for others who r~t:bj Midlands Partnership NHS Foundation Trust A Keele University Teaching Trust live close to county boundaries. I wonder if anything can be done to facilitate arrangements for secondary psychiatric care in these circumstances. Following discussions within the mental health seNices in the Staffordshire and Stoke on Trent Care Group and with corporate seNices, I am now in a position to respond to the specific concern raised during the course of the inquest. In 2020, the period covered in the serious incident investigation report, Mrs Adams had contact with a number of mental health providers during periods of crisis, according to the geography you describe in the matter of concern. Mrs Adams lived in Dosthill, Tamworth, and it would not be uncommon for individuals in Tamworth to touch on services delivered by the three NHS providers described here: • Midlands Partnership Foundation Trust (MPFT): Mrs Adams' husband contacted the Access pathway in MPFT - pathway staff would offer advice, and forward any calls to the MPFT crisis resolution team when Mrs Adams was in crisis; these assessments would always be offered when required. They would also offer details for Coventry and Warwickshire services as Mrs Adams' commissioned provider, should she require future interventions. • Birmingham and Solihull Mental Health Foundation trust (BSMHFT): Mrs Adams frequently attended Good Hope Hospital where she was seen by the mental health liaison team, a seNice delivered by BSMHFT. The BSMHFT liaison team communicated with the Access team at MPFT and identified no mental health needs that necessitated care from secondary seNices. • Coventry and Warwickshire Partnership NHS Trust (CWPT): As Mrs Adams' GP commissioned services from CWPT, advice would be for their services to be accessed where needed. However, when she was in a period of crisis the assessment would be undertaken by the team who were geographically closer to where she was. For example, on 19th July 2020 CWPT crisis team communicated with MPFT, MPFT provided the response to Mrs Adams with no delay. Throughout this period Mrs Adams' difficulties were deemed to be related to alcohol misuse with no acute mental health problems that would require secondary mental health services. In earlier years when Mrs Adams did require a secondary mental health services (1999 - 2005, 2014-2015, 2018, 2019) this was offered by MPFT (or the predecessor organisation South Staffordshire and Shropshire Foundation Trust). Throughout all of Mrs Adams' episodes of care, including that in 2020, MPFT has worked well with partners to ensure people living on the county border are not disadvantaged in terms of seNices offered and in delivering patient-centred collaborative working between organisations. However, given your concerns, we believe the matter is one for commissioners to consider and have therefore forwarded this case to them for their consideration and are happy to support the outcome of those conversations, as appropriate. r~L:kj Midlands Partnership NHS Foundation Trust A Keele University Teaching Trust I hope this response helps to address your concerns. However, if you require any further information please do not hesitate to contact me. Yours sincerely Chief Executive
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