Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0124, written 28 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 | 28 Apr 2021 |
|---|---|
| Reference | 2021-0124 |
| Deceased | Sean Kay |
| Coroner | Sean Horstead |
| Coroner area | Cambridgeshire & Peterborough |
| Category | Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Community health care · Suicide (from 2015) |
| 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: 1. Chief Officer NHS Norfolk and Waveney CCG, Lakeside 400, Old Chapel Way, Broadland Business Park, Thorpe St Andrew, Norwich, NR7 0WG 1 CORONER I am Sean Horstead, assistant coroner, for the coroner area of Cambridgeshire & Peterborough 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 28th February 2020 I commenced an investigation into the death of Sean Kay, 50 years of age. The investigation concluded at the end of the inquest on 3rd November 2020. The conclusion of the inquest was one of suicide. The medical cause of death was I(a) drowning; II Zopiclone and morphine intake. 4 CIRCUMSTANCES OF THE DEATH Sean Kay had been suffering from mental health problems, including anxiety disorder, insomnia and (latterly) depression for some years. He received medication for his anxiety and low mood from his GP but to limited beneficial effect. In December 2019 he was referred by his GP to the mental health services of the Norfolk & Suffolk NHS Foundation Trust. Mr Kay was referred to the Early Intervention in Psychosis Team (EIPT) who, after assessment, determined he did not meet the criteria for first episode of psychosis. As a consequence, EIPT planned to encourage him to continue to work with the (primary care) Wellbeing Services (WBS) with whom he had contact from January 2020. However, because of the added complexity that Sean had been identified by the EIPT as being in the 'at risk mental state' (ARMS) cohort of patients, he was deemed to be too complex for the WBS, by the WBS. An 'Interface Team Meeting' involving (amongst others) the WBS and the EIPT, scheduled for the 20th February 2020, to discuss the future care provision for Mr Kay, did not take place due to an administrative error and Mr Kay was not discussed at the meeting as planned. Consequently, at the time of his death six days later, Mr Kay was awaiting confirmation of whether – and/or from whom - he would be receiving support for his on-going mental health concerns. On 26th February 2020 Mr Kay's body was recovered from an area of water near Stonea Bridge on Sixteen Foot Bank, Stonea. Life was confirmed extinct at the scene. Mr Kay had taken his own life whilst the balance of his mind was disturbed. 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. The MATTERS OF CONCERN are as follows. – The evidence clearly identified a gap in service provision in the Norfolk and Waveney area for the cohort of patients into which Sean fitted. Although having been identified as ARMS by the EIPT in Norfolk and Waveney, Sean nonetheless did not fit the strict criteria for accessing that service as he was deemed to have not yet suffered a first episode of psychosis; however his level of risk was sufficiently high that he was also considered unsuitable for WBS. Additionally, the evidence confirmed that Sean did not fit the criteria of either the Community Mental Health Team, the Crisis Team or MIND. In contrast, in the neighbouring Suffolk area (and the evidence suggested in many other areas of the country) ARMS patients are recognised as falling under the commissioned EIPT umbrella and therefore receive commissioned assessment, treatment and management from that team. This lacunae in service provision in Norfolk and Waveney meant that, at the time of his death, Sean fell between services and did not receive any appropriate care. opinion the continuation of such a lacunae in commissioned service provision gives rise to the risk of future deaths. In my 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or 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 23rd 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of the deceased; Norfolk and Suffolk NHS Foundation Trust. 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. Sean Horstead HM Assistant Coroner for Cambridgeshire & Peterborough 28th April 2021 9 2
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.
20 July 2021
Mr S Horstead
HM Coroner’s Office for Cambridgeshire and Peterborough
Lakeside 400
Old Chapel Way
Broadland Business Park
Thorpe St Andrew
Norwich
NR7 0WG
Re: Mr Sean Kay Inquest – response to Regulation 28 Report
Dear Mr Horstead,
Introduction
Thank you for the Regulation 28 Report dated 28 April 2021, regarding the inquest of Mr Sean
Kay. We understand that the inquest was heard on 3 November 2020. The CCG was not invited
to, nor involved in the inquest hearing. Although the Regulation report was not sent to the CCG
directly, but we have since received it via Norfolk and Suffolk NHS Foundation Trust, and we
understand that you require a response from the CCG.
We have listened to the audio record of the inquest; thank you for providing a copy. We
understand that you have concerns about commissioning, based on the oral evidence you heard
, Community Team Manager for the Early Intervention in Psychosis (EIP)
from
Services at Norfolk and Suffolk NHS Foundation Trust. Sean Kay had been provided with mental
health care by Norfolk and Suffolk NHS Foundation Trust.
As a result of that evidence, we understand that you are concerned that there is a gap in the
commissioned mental health services for patients who have been assessed to have an “At Risk
Mental State” (ARM) before psychosis in the Norfolk area1. You were told that it was not clear
which team within Norfolk and Suffolk NHS Foundation Trust would continue to offer care for Mr
Kay, and that a planned meeting between a number of their teams to discuss and agree this
(EIP, Wellbeing and CMHT) did not take place before his death. It seems that some of their
teams felt that they would not be responsible for Mr Kay, because of the criteria that they have
for each team. You were also told that in other geographical areas, an ARMS patient would be
managed by their Wellbeing Team. It is unfortunate that you were given oral evidence about
commissioning in our absence.
The EIP service in Norfolk and Waveney
Norfolk and Suffolk Foundation Trust (NSFT) provide an Early Intervention in Psychosis (EIP)
service for Norfolk and Waveney. The service is commissioned to support patients from the age
of 14. There has been significant investment between 2017 and 2021 to the value of about £1.2
million as per the Long Term Plan ambition.
1 Typically, before an episode of psychosis, many people will experience a relatively long period of symptoms, which
is described as having an ‘at risk mental state’, often shortened to ARMS. This may include: a more extended period
of less severe psychotic symptoms; or an episode of psychosis lasting less than seven days; or an extended period
of very poor social and cognitive functioning (perhaps accompanied by unusual behaviour including withdrawal from
school or friends and family) in the context of a family history of psychosis. When treating a person presenting with an
at risk mental state, it is important both to support them with their current needs as well as to try to prevent transition
to psychosis. Implementing the Early Intervention in Psychosis Access and Waiting Time Standard: Guidance, NICE,
2016.
1
The EIP service delivers a NICE recommended package of care to patients within two weeks of
referral to 77.2% of patients entering the service. This is significantly above the nationally
mandated target of 50% at the time of the incident, to 60% currently.
Norfolk and Waveney EIP service has recently been audited as part of the National Clinical Audit
of Psychosis (NCAP) audit (2020/21 is Year 4). The audit explores the level of care provided to
patients by EIP services resulting in a rating between 1 (low) and 4 (excellent/ comprehensive).
The standards are based on the 2016 Early Intervention in Psychosis Access and Waiting Time
Standard.
The CCG is clear that Mr Kay should have been provided with mental health services by Norfolk
and Suffolk NHS Foundation Trust, and that it is not the case that there is a gap in
commissioning. The CCG commissions mental health services for the local population. There is
no commissioning reason why ARMs patients cannot be cared for by either the EIP, or the
Wellbeing team, or the CMHT. Which team deals with each patient is a matter for the Trust to
determine, and ensure that their staff understand their chosen approach. It appears from the oral
evidence of Ms Tingey that, in fact, Mr Kay could and should have been cared for by the EIP.
As a commissioner, we are concerned that Mr Kay was not provided with the care that he
needed. We have contacted Norfolk and Suffolk NHS Foundation Trust, which has confirmed to
us that as a result of this sad case, they have made sure they have better communication
channels and education between their teams, to ensure people do receive the help they need.
Norfolk and Suffolk NHS Foundation Trust informed us as follows:
“In respect of the management of patients currently transferring between teams, as you
will be aware we have a Trust policy which covers this, and outlines the necessity for the
original team to proactively ‘hold’ the patient until a firm handover is achieved. This is
underpinned by improved regular interface meetings between teams, to ensure patients
are known and receiving the right support delivered by the right team.
A number of improvement initiatives, including a QI project on communication between
teams, were undertaken in West Norfolk, as was a reflective learning session and
individual capability actions completed; all as a result of the Trust review. Communication
with carers of patients under EIS was also strengthened as a result of the review into
Sean’s death, built on discussions with his family”.
Conclusion
Where there is a concern about oral evidence given about commissioning in future; we would be
grateful to be informed by letter, and given the opportunity to provide accurate information about
our commissioning.
Yours sincerely
Chief Nurse
NHS Norfolk and Waveney CCG
2
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