Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0126, written 30 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 | 30 Apr 2021 |
|---|---|
| Reference | 2021-0126 |
| Deceased | Joanna Leven |
| Coroner | Chris Morris |
| Coroner area | Greater Manchester South |
| Category | Mental Health related deaths · Suicide (from 2015) · Community health care and emergency services related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Care NHS Foundation Trust · North West Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt.Hon. Matt Hancock MP, Secretary of State for Health and Social Care. 1 | CORONER | | |am Chris Morris, Area Coroner for the coroner area of Greater Manchester (South). 2 | CORONER'S LEGAL POWERS 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 | INVESTIGATION and INQUEST On 9th April 2020, | opened an inquest into the death of Joanna Leven who was found dead at her home on 26th March 2020, aged 34 years. A post mortem examination undertaken by Dr aoranet consultant pathologist, determined that Ms. Leven died as a result of asphyxia. The coronial investigation into her death concluded with the inquest, which was heard before me on 26th — 27th April 2021, resulting in a conclusion that Ms. Leven had died as a consequence of suicide. | make this report under Coroners and Justice Act 2009, paragraph 7, Schedule ° CIRCUMSTANCES OF THE DEATH Ms. Leven was found dead at her home on 26th March 2020 as a consequence of asphyxia which was self- induced with the intention of bringing about her death. Ms. Leven was under the care of community mental health services having previously been diagnosed with Emotionally Unstable Personality Disorder arising from traumatic experiences in childhood. As a result of her Personality Disorder, Ms. Leven had frequently self- harmed and/or attempted suicide, often telling others what she had done. A major protective factor in maintaining Ms. Leven's safety was her dog. In February 2020, Ms. Leven's dog became seriously unwell. This led to a profound deterioration in her mental health. After Ms. Leven'’s dog was euthanized in March 2020, she cut her groin and took a mixed overdose, resulting in her being taken to hospital. Whilst she received treatment there for her physical health, Ms Leven left hospital before the mental health liaison team could assess her. Despite the clear deterioration in Ms. Leven's health, the removal of the major protective factor in maintaining her safety and her e-mailing her care coordinator to inform him she intended to complete suicide after leaving hospital, no comprehensive mental health assessment took place. It is possible the absence of a comprehensive mental health assessment at this point in Ms. Levens life might have contributed to her death. 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. — | 1) The court heard evidence that there is no national therapeutic pathway for | treatment of Personality Disorders. Whilst the court heard steps are in place to introduce a loca! pathway for residents of Greater Manchester, it is understood eligibility for and availability of various therapies which may be beneficial to patients diagnosed with a Personality Disorder varies from place to place; 2) Evidence was heard in court to the effect that there are gaps in provision by | statutory agencies of counselling and other mental health services specifically tailored for victims of trauma, violence and domestic abuse. In Stockport, specialist services of this nature fall to be provided by a registered charity with | only short-term funding in place, a position which is understood to be replicated elsewhere in the country; | 3)The court heard evidence that, where a patient attends a Hospital Emergency Department with both physical and mental health needs, it is usually the case that Hospital and Mental Health Liaison staff are working with different computer-based records systems. This creates an obvious risk of information being lost or incompletely conveyed as between different professional groups. ACTION SHOULD BE TAKEN | In my opinion, action should be taken to prevent future deaths and | believe that you and/or your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25th 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. COPIES and PUBLICATION | have sent a copy of my report to the following: - HHJ Thomas Teague QC, the Chief Coroner of England and Wales; FY on behalf of Ms Leven’s family; hi: Stockport Metropolitan Borough Council; ; Hempsons LLP, Solicitors to Pennine Care NHS Foundation Trust; ; of Weightmans LLP, Solicitors to North West Ambulance Service NHS Trust; : oc To Greater Manchester Police; . fs OG Stockport Without Abuse; and a. Independent Chair, Safeguarding Adult Review. | am 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. 30" April 2021 Christopher Morris, HM Area Coroner, Manchestef South.
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.
From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H 0EU Mr Christopher Morris HM Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris 15 July 2021 Thank you for your letter of 30 April 2021 about the death of Joanna Leven. I am replying as Minister with responsibility for mental health services and suicide prevention. I would like to begin by saying how deeply sorry I was to read the circumstances of Ms Leven’s death and I offer my deepest sympathies to Ms Leven’s family and loved ones. In preparing this response, Departmental officials have made enquiries with NHS England and NHS Improvement (NHSEI) and the Care Quality Commission (CQC). I am also aware that the Stockport Clinical Commissioning Group (CCG) has written to advise you of the local action that is being taken to improve services for patients with serious mental illness, including personality disorders. I would like to assure you and those who knew and cared for Ms Leven that we are committed to ensuring that people have access to the right mental health support, in the right place, and at the right time and that improving mental health services for people with severe mental illness, including personality disorders, is a key priority for the Government. Under the NHS Long Term Plan, we are investing almost £1billion extra in community mental health care for adults by 2023/24. New and integrated models of primary and community mental health care will give 370,000 adults with serious mental illnesses, including personality disorders, greater choice and control over their care and support them to live well in their communities by 2023/24. This care and support will include access to psychological therapies; improved physical health care; employment support; personalised and trauma-informed care; medicines management; and, support for self-harm and coexisting substance use. Local areas will be supported to redesign and reorganise core community mental health teams to move towards a new place-based, multidisciplinary service across health and social care aligned with primary care networks. Furthermore, as part of the Spending Review 2020, we have announced that the NHS will receive around an additional £500million in 2021/22, to address waiting times for mental health services, give more people the mental health support they need, and invest in the NHS workforce. How the funding will be used is set out in our COVID-19 mental health and wellbeing recovery action plan. The recovery action plan also includes details of the funding we have provided to support mental health throughout the pandemic. £58million will be used to accelerate the roll-out of the community mental health framework to treat adults and older adults with serious mental illness, specifically: • Bringing forward the expansion of integrated primary and secondary care for adults and older adults with serious mental illness; • Embedding mental health practitioner roles in primary care networks across the country from 2021 to 2022 to better meet the needs of people living with severe mental illnesses in primary care; • Expanding peer support and non-clinical workforce to boost the capacity of community mental health services; and, • Accelerating transformation across eating disorder pathways, with a focus on early intervention models and close working with voluntary and community sector partners. In relation to commissioning mental health services for victims of trauma, violence and domestic abuse, local clinical commissioning groups are responsible for decisions about commissioning services to meet the needs of their local populations. Services may be provided by a range of organisations, including NHS and private providers, and providers in the voluntary, community and social enterprises. We continue to take steps nationally to ensure that victims of abuse and domestic abuse have timely access to care and support. As laid out in the recovery action plan, the Government is providing £40million in 2021/22 to boost specialist support services for victims of rape and domestic abuse. This includes: over £20million for local community- based sexual violence and domestic abuse services, to help reduce the amount of time survivors wait for support; £16million to recruit more independent sexual violence and domestic abuse advisers; and £2million for smaller, specialist organisations that help ethnic minority, LGBT or disabled victims. Turning to your concerns about improving information sharing between services and professional groups, effective information sharing is vital to support improved patient outcomes. The NHS Long Term Plan Implementation Framework makes several commitments to improve information sharing. By 2024, all secondary care providers should be fully digitised and integrated with other parts of the health and care system, for example, through a local health and care record platform. Shared care records ensure that information and care plans are available across health and social care to support planning, better risk management and ensure care is more joined up and delivered around an individual’s needs. NHSX, responsible for digital transformation strategy, expects all areas to have a basic minimum viable shared care record in place by September 2021. This work builds on the Local Health and Care Record programme and will provide access to patient records across organizational boundaries, including between mental health services and acute hospitals. Finally, we are taking action more broadly with the aim of reducing suicide rates and ensuring that fewer people take their own life each year. We are investing an additional £57million in suicide prevention by 2023/24 through the NHS Long Term Plan. This will see investment in all areas of the country to support local suicide prevention plans and the development of suicide bereavement services. In addition, we are also providing an extra £5million in 2021/22, to be made available specifically to support suicide prevention voluntary and community sector organisations, with part of this set as a grant fund to help ensure that the financial gaps incurred as a result of additional pressures during COVID- 19, are covered. I hope this response assures you, and Ms Leven’s family, that we are taking action nationally to ensure that people can get access to vital mental health support sooner and in the community wherever possible. Thank you for bringing these concerns to my attention. NADINE DORRIES MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENATL HEALTH
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