Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0183, written 28 May 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 May 2021 |
|---|---|
| Reference | 2021-0183 |
| Deceased | Angela Frost |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) · Alcohol, drug and medication related deaths |
| Organisation named | Pennine Care NHS Foundation Trust |
| 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
EE = ecutive Medical Director, Pennine Care NHS Foundation Trust
CORONER
| am Catherine McKenna, Area Coroner for the Coroner area of Manchester North
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013
INVESTIGATION and INQUEST
On 28 August 2020 | commenced an investigation into the death of Angela Marie FROST. The investigation
concluded at the end of the inquest on 21 May 2021. The medical cause of death was (1a) Amitriptyline
Overdose. The conclusion of the inquest was ‘suicide whilst the balance of her mind was disturbed.’
CIRCUMSTANCES OF DEATH
The Deceased was admitted to Aspen Ward, Royal Oldham Hospital on 8 June 2020 following a mixed
overdose. She complained of sensations which included feeling that her insides ‘melting,’ that she had ‘hot
lava’ and ‘snakes in her stomach’ and ‘a brain haemorrhage causing trickling in her head.’ Hormonal tests
undertaken during the admission established that the Deceased was post-menopausal. The Consultant
Psychiatrist with responsibility for the Deceased was of the opinion that the sensations where related to the
menopause rather than a psychosis. A GP trainee spoke to a Gynaecology Registrar who advised that HRT
was contraindicated and recommended the use of herbal alternatives. The Deceased declined to take the
herbal alternative and was discharged from the ward on 2 July 2020 on anti-psychotic medication. The
Consultant Psychiatrist recommendation that a referral be made by primary care to Gynaecology to discuss
HRT alternatives was not communicated to the Deceased's GP.
On 21 July 2020, the Deceased was re-admitted to Aspen Ward after being located in woodland. She had
been missing for 7 days with the express intention that she starve herself to death. During her second
admission, her anti-psychotic medication was increased. The Consultant Psychiatrist formulated a diagnosis
of ‘profound menopause with secondary kinaesthetic hallucinatory experiences.’ These diagnosis does not
feature in ICD-10 and a second opinion was not requested or obtained by the Consultant Psychiatrist. No
contact was made with the Specialist Pharmacist attached to the locality to establish whether HRT was
contraindicated and no further contact was made with the Gynaecology team. Had enquiries been made with
the pharmacy team, it is more likely than not that it would have established that HRT was not absolutely
contraindicated and therefore would have been a potential treatment option.
The Deceased’s family members were not involved in discussions around all available treatment options and
despite leaving messages for the Consultant Psychiatrist to contact them, sufficient enquiries were not made
as to whether the Deceased consented to their involvement in her care. It is more likely than not that had
sufficient enquiries been made, the Deceased would have consented to sharing information with her family
which would have provided her with a source of support in her decision-making.
The Deceased took her own discharge from the ward on 7 August 2020. A table-top review meeting was held
on the same day in which the Early Intervention Team were updated on the Deceased’s condition. The
Deceased was last seen by a mental health professional on 20 August 2020 during which she described an
improvement in her symptoms. She was found deceased at her home address on 24 August 2020 having
taken an intentional overdose of her partner's old medication.
§ 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) There is no formal guidance or process in place at the Trust for Consultant Psychiatrists to seek a second
opinion in relation to diagnosis, treatment plans or whether a patient meets the criteria for detention under the
Mental Health Act. The evidence was that whilst there is nothing to prohibit a Consultant requesting a second
opinion, it rarely happens in practice.
(2) There is no formal guidance or process in place at the Trust for health care professionals or family members
to seek a second opinion in relation to the matters set out above.
(3) The court heard evidence that there is a lack of understanding on the part of in-patient Consultants as to
rules around confidentiality and the nature/extent of permissible communication with family members ie: the
difference between receiving information which might inform diagnosis, treatment and risk planning and
discussions which involve sharing confidential health information.
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.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely 23 July 2021.
|, the Area 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 expiain 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 namely:-
e
e
| have also sent a copy to the Care Quality Commission who may find it useful or of interest.
| 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 from. 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.
Date: 28 May 2021 Signed: C {|| y
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.
Corporate Services Trust Headquarters 225 Old Street Ashton Under Lyne Lancashire OL6 7SF 21 July 2021 Private & Confidential Mrs C McKenna HM Area Coroner HM Coroner’s Court Floors 2 & 3, Newgate House, Newgate Rochdale OL16 1AT Dear Ms McKenna I write in response to your Regulation 28 report dated 28th May 2021 and in respect of the concern you have highlighted after hearing evidence of the inquest of Ms Angela Frost. Your concern has been reviewed and Pennine Care's response is outlined below. Coroners Concern (1) There is no formal guidance or process in place at the Trust for Consultant Psychiatrists to seek a second opinion in relation to diagnosis, treatment plans or whether a patient meets the criteria for detention under the Mental Health Act. The evidence was that while there is nothing to prohibit a Consultant requesting a second opinion, it rarely happens in practice. (2) There is no formal guidance or process in place at the Trust for health care professionals or family members to seek a second opinion in relation to the matters set out above. Since Ms Frost's untimely death, the Triumvirate Leadership Team for Oldham's Mental Health Services has reviewed the Trusts internal processes to request second opinions. Below is a summary of the work that has been done so far: - A draft process for requesting second opinions has been written, and this will be submitted to the Trusts Quality Group for scrutiny and sign-off. The process includes guidance for how Consultant Psychiatrists, Health Care Professionals, patients, families and carers can request a second opinion. - The process will be implemented across all of Pennine Care NHS Foundation Trust's (PCFT's) services. - The draft process is attached. (3) The court heard evidence that there is a lack of understanding on the part of inpatient Consultants as to rules around confidentiality and the nature/extent of permissible communication with family members i.e.: the difference between receiving information which might inform diagnosis, treatment and risk planning and discussions which involve sharing confidential health information. (Consultant Psychiatrist and Clinical Director) has reviewed the concerns related to Consultant Psychiatrists lack of understanding of rules pertaining to confidentiality and sharing information with family and carers. Consultant Psychiatrists The serious incident investigation that was submitted to HM Coroner as evidence for the Inquest of Ms Frost identified individual performance issues with the Aspen Ward Consultant Psychiatrist involved in Ms Frosts care and treatment. The Consultant Psychiatrist is involved in an informal performance management programme. All Consultant Psychiatrists employed by PCFT complete training, which covers issues related to information sharing. The training courses include: - Mental Capacity Act - Deprivation of Liberty Safeguards - Safeguarding Children and Adults - Section 12 and Approved Clinician Course (Mental Health Act, 1983) Consultant Psychiatrists also access annual appraisals and can access case-based discussions with senior consultants, both of which are supportive mechanisms that support clinical practice. Triangle of Care PCFT is also a member of the Triangle of Care initiative. The 'Triangle of Care' is a working collaboration, or "therapeutic alliance" between the service user, professional and carer that promotes safety, supports recovery and sustains well- being. PCFT first introduced our Trust-wide Triangle of Care steering group in 2014, followed by the establishment of each borough's local steering group to build on our success. This included Oldham. Before the Covid-19 pandemic, our momentum slowed as some of the local steering groups Chairs were lost, and carer champions moved posts. Covid-19 compounded these difficulties as a result of the pressures placed on services. Our Trust-wide steering group has re-commenced following it being stood down due to Covid-19. To regain our momentum with Triangle of Care, we are currently: - Undertaking a survey of inpatient and community service managers about the extent to which services are currently able to meet standards, seek examples of good practice and understand any barriers that there may be implementing. This includes our services in Oldham. - Collating a survey of carers undertaken where we sought examples of how it feels when we achieve each of the six key standards and when we do not. This will supplement the survey sent to inpatient and community service managers to provide a lived-experience context to the exercise. We will also consider how else this could usefully be used, for example, in training. - We are working with our Network Directors of Quality to identify Chairs and local approaches to steering groups; again, this includes Oldham. As we complete the work outlined above, we will move forward by: - Holding a co-design workshop with the identified local lead/Chairs and carers to establish the framework/agenda that local forums will work to and decide the areas that should be prioritised. The outcome of our survey across our services will be used to inform this piece of work. - Arranging a co-designed re-launch of the Triangle of Care, Trust-wide and in each borough, to reinvigorate our work and to promote it and build engagement internally and externally. - Complete our annual report to ensure that we retain our first star and co- design a plan to move towards our second. - Continue national conversations and if there is a continued absence of regional or national groups, seek to establish a group with other Trusts to promote inter-organisational learning. In January 2021, PCFT appointed and Carer Experience and Engagement. the Trust to develop further and embed the principles of Triangle of Care in mental health services. to the new role of Head of Patient continues to work with services across I trust this response assures you that the Trust has taken your concern seriously and has thoroughly reviewed the issues raised. Yours sincerely Executive Medical Director
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