Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0260, written 29 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jul 2021 |
|---|---|
| Reference | 2021-0260 |
| Deceased | James Nowshadi |
| Coroner | Caroline Jones |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Mental Health related deaths · Suicide (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Department of Health and Social Care and Public Health England (as the bodies responsible for the National Poisons Information Service) 2 The Royal College of Psychiatrists 1 CORONER I am Caroline JONES, Assistant Coroner for the coroner area of Cambridgeshire and 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 16 April 2020, an investigation was commenced into the death of JAMES MICHAEL NOWSHADI aged 23 years. The investigation concluded at the end of the inquest on 23 June 2021. The conclusion of the inquest was: James’ death was a suicide, caused by him deliberately ingesting James had a long-standing history of depression for which he was latterly involved with the Cambridgeshire & Peterborough NHS Foundation Mental Health Trust, and had expressed his that he had ordered via the internet clear intent to end his own life by taking from Poland. Because he was deemed to have capacity, it was not thought appropriate to inform his family (with whom he lived) of his intentions, even if their intervention could have potentially prevented his death There was little knowledge or understanding of the role of involved in James’ care and insufficient exploration of how James had alighted upon in suicides by those as the means by which he proposed to end his life, which meant that there was also inadequate consideration of whether this could be a factor in other patients’ suicidal ideation. 4 CIRCUMSTANCES OF THE DEATH James had a history of depression and low mood. From 2016 onwards, he was in receipt of regular therapy and counselling which seemed to have improved his mental wellbeing but in early 2020, he was referred to mental health services when he began expressing specific plans to end his own life. James was seen by clinicians from various teams where he disclosed further details about his intentions. He did not want information about his plans to be disclosed to his family. James was considered to have capacity to make decisions about his care. Although consideration was given to whether to override his stated wishes and inform his family so that they could help to safeguard him, it was felt that the risk of suicide was insufficiently imminent to warrant breaching his right to confidentiality. Prior to commencing treatment, James had ordered via the internet a quantity of , which he proposed to take at a future date as a means of ending his life. He was open about his plans with those treating him but could not be persuaded to share his thoughts with his family nor dispose of the . He agreed to continuing engagement with mental health services and was deemed not to meet the criteria for admission to hospital. In late March 2020, James had not put into effect his plans and appeared to be looking forward to starting a new job and engaging with new psychological treatment options. On the evening of 31 March 2020, James was found unresponsive in his bedroom at the family home, before he had a seizure. An ambulance was called and paramedics attended and gave him emergency care but he went into cardiac arrest. He was taken to Addenbrooke’s hospital where despite further attempts at resuscitation, he was pronounced dead at 01.47 hours on 1 April 2020. Tests on his blood revealed that he had a methaemoglobin level of 90% as a likely consequence of ingesting the . It is very unlikely that any further medical intervention could have changed the outcome and the prolonged period in cardiac arrest was thought to be unsurvivable. 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 CONCERNS are as follows: 1. There does not appear to be any national guidance available to psychiatrists and mental health practitioners dealing with possible cases. Those involved in James’ care made insufficient effort to research or evaluate the potential risks and consequences of James obtaining and using the to end his life and any information that was obtained from brief internet searches was not disseminated to colleagues beyond those immediately involved in James’ case only. I am concerned that there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite. 2. The family raised concerns about the risks of in suicides as part of the Serious Incident Review undertaken by the Trust but this section was omitted from the final report at the direction of the SIR review panel. This meant that there was a missed opportunity for the Trust to reflect on lessons that may properly be learned from James’ death, an omission which they now appear to be taking steps to remedy. However, I am concerned that there is a risk of future fatalities at a national level if Mental Health Trusts are not using Serious Incident Reviews and other internal investigations to learn lessons from suicide cases, including about the risks presented by sodium nitrate/nitrite. 3. The inquest heard evidence from a senior Accident & Emergency doctor about the information available from the National Poisons Information Service to emergency departments who . This included information about encounter patients who have ingested the potential availability of an antidote, ‘methylene blue’. However, there is apparently no national guidance about the appropriate use of the antidote in cases involving cardiac arrest and whether attempts should be made to administer it in such cases. I am concerned that there is a risk of future fatalities if A&E clinicians do not have access to comprehensive and up-to-date information about toxic substances and their possible antidotes to know when – and when not – to administer treatment. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 23 September 202123 September 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: 1. 2. The Cambridgeshire & Peterborough NHS Foundation Trust. , mother of James Nowshadi 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. 9 Caroline JONES Assistant Coroner for Cambridgeshire and Peterborough Dated: 29/07/2021
2 responses 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 Gillian Keegan MP Minister of State for Care and Mental Health 39 Victoria Street London SW1H 0EU Ms Caroline Jones HM Assistant Coroner, Cambridgeshire and Peterborough HM Coroner's Office Lawrence Court Princes Street Huntingdon PE29 3PA 10 December 2021 Dear Ms Jones, I am writing in relation to the Prevention of Future Deaths report issued on 29 July 2021, which came to the Department’s attention on 27 September 2021, about the death of James Nowshadi. I am replying as Minister with responsibility for mental health and I am grateful for the additional time in which to do so. Firstly, I would like to say how very sorry I was to read the circumstances of Mr Nowshadi’s death and I offer my deepest condolences to his family and all who loved and knew James. I can appreciate that his loss, at such a young age and in such circumstances, is deeply distressing. I share your concerns about the ease with which a person can obtain chemicals, such as that mentioned in your report, for the purpose of taking their own life, and I can assure you that in relation to this specific chemical, we are taking action with other Government departments, health bodies, academic experts on self-harm and suicide prevention, and third sector stakeholders, to look at how to tackle the use of this and similar chemicals in suicides. As part of this work, NHS England and NHS Improvement advises that a communication will be sent to mental health trusts to bring their attention to the risks associated with this chemical as a means of suicide and the need to seek advice from the National Poisons Information Service (NPIS). The chemical used in this case is available to the public for legitimate uses. However, it is also included in The Poisons Act 1972 as a reportable substance. This means that while this chemical is generally available without the need for a licence, sellers (including online sellers) are obligated to make suspicious transaction reports, whether they process the transaction or not, where they have grounds to believe that the sale is for an illicit use. Officials inform me that the Home Office regularly engages with suppliers to help them meet their requirements under the Poisons Act and that the Home Office provides detailed guidance1 in relation to any additional safeguarding steps suppliers could take. More broadly, as detailed in the fifth progress report of the suicide prevention strategy, published in March 20212, it is important that we identify trends in methods of suicides as quickly as possible and put in place interventions to rapidly tackle any emerging methods identified. A process has been established with partners and across Government to rapidly signpost emerging methods and take actions through a multi-agency approach. This includes, but is not limited to, limiting access to the method, reducing or removing promotional material where possible, and providing clearer warnings of risk. Trust Serious Incident Investigation I have noted the comments in your report in relation to the investigation conducted by the Cambridgeshire and Peterborough NHS Foundation Trust. I am advised by the Trust that the Medical Director and the Chief Executive met Mr Nowshadi’s family to understand their concerns. A subsequent review of the Serious Incident investigation report identified that reference was made to this chemical. I have received assurance that the Trust is working with the family to ensure lessons are learnt regarding this chemical being used as a method of suicide, and that the risks associated with it are addressed as part of the Trust’s Zero Suicide work. Guidance on use of antidote In relation to your third matter of concern, in preparing this response, my officials have made enquiries with the UK Health Security Agency and I am informed by the NPIS that its internet database, TOXBASE, has pages on sodium nitrate/nitrite and methylthionium chloride (‘mythylene blue’) but that it appears these were not accessed from anywhere in the Cambridge area on 31 March 2020 and 1 April 2020. The NPIS advise that TOXBASE cannot provide advice for every potential clinical scenario or eventuality following poisoning. However, if the NPIS had been contacted regarding this case (a 24-hour telephone advice line is staffed by specialists in poisons information), more specific clinical management advice could have been provided, with support from on call toxicologists if necessary. Finally, we know how crucial it is that information about a suicide is treated with the utmost sensitivity it deserves, not only for the bereaved families and communities, but also because reporting on the particulars of an individual suicide can lead to other people taking their life in similar ways, be that in the same location or by the same method. With this in mind, and with due respect to the Chief Coroner’s rights under the Coroners (Investigations) Regulations 2013 to publish this response, I wish to reiterate the need for 1 Supplying explosives precursors and poisons - GOV.UK (www.gov.uk) 2 Suicide prevention in England: fifth progress report - GOV.UK (www.gov.uk) us, as far as possible, to ensure the media practice caution when making public any facts or details relating to this method. I hope this response is helpful. Thank you for bringing these concerns to my attention. GILLIAN KEEGAN
Caroline Jones Assistant Coroner Cambridgeshire & Peterborough Coronial Service Lawrence Court, Princes Street, Huntingdon, PE29 3PA Dear Ms Jones Royal College of Psychiatrists response to Coroner’s Report into the death of James Nowshadi Purpose of response To respond to the issues raised in relation to the tragic death of James Nowshadi, particularly regarding the awareness of psychiatrists on how to respond if they are made aware of the use of by one of their patients. We would first like to take the opportunity to extend our sincere and deepest sympathies to James's family, friends and all who knew him. Background The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists throughout their careers, from training through to retirement, and in setting and raising standards of psychiatry in the United Kingdom. The College aims to improve the outcomes of people with mental illness, and the mental health of individuals, their families and communities. In order to achieve this, the College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers, and their organisations. Nationally and internationally, the College has a vital role in representing the expertise of the psychiatric profession to governments and other agencies. While these are extremely tragic circumstances on which to have to communicate, we hope that the information we provide in this note responds to the issues raised that are relevant to the College and that it may contribute to minimising the risk of similar events occurring in the future. If you have any questions or would like to discuss any aspect of our response, please do not hesitate to contact us at Guidance to psychiatrists on the harms associated with the use of Sodium Nitrate as a noted contributory factor to these tragic On reviewing national data associated with deaths by suicide, we have not been able to identify incidents. We would welcome any additional information that might be available on this particular substance and its role in any deaths. We are happy to raise this matter with those bodies who have responsibility for such data reporting and collection, although appreciate you might have already directly raised it with them. Where we think the College can have more direct effect is ensuring psychiatrists understand how to effectively explore and respond to issues associated with medications and substances that they are aware their patients are taking or have access to. It is crucial that clinicians use any such information, provided by the patient or elsewhere and make an evaluation of risk, taking action where needed. In reinforcing some of the key risk advice around this, we can specifically refer to to focus on this in a broader way to optimise the impact of any such communication. We will look for opportunities to do this in the near future. but hope you will agree it would be good In relation to the Emergency Department aspect of your Report, while we do not directly control this, we would be happy to ask those with responsibility for treatment in this setting if they might consider adding where needed and , for enhancing where reference might already exist, mention of example on the toxicology sites that clinicians might refer to in an Emergency Department. Please do not hesitate to contact me if I can be of any assistance. Yours sincerely, Registrar Royal College of Psychiatrists
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