Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0354, written 16 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Oct 2021 |
|---|---|
| Reference | 2021-0354 |
| Deceased | Sky Rollings |
| Coroner | Emma Serrano |
| Coroner area | Stoke-on-Trent & North Staffordshire Coroner’s Court |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) · Child Death (from 2015) |
| 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 THIS REPORT IS BEING SENT TO: 1) NORTH STAFFORSHIRE COMBINED HEALTHCARE; AND 2) NHS ENGLAND 1 CORONER I am Emma Serrano Area Coroner for Stoke-on-Trent & North Staffordshire Coroner's Court 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 21/11/2019 I commenced an investigation into the death of Sky Louise Rollings, aged 18. The investigation concluded at the end of the inquest on 14th October 2021. The conclusion of the inquest was Misadventure contributed to by Neglect. 4 CIRCUMSTANCES OF THE DEATH Sky Louise Rollings suffered with Emotionally Unstable Personality Disorder (“EUPD”) was sectioned under the mental health Act. She was resident at the Harplands Hospital when she on the 8 November 2019. She passed away on the 9 November 2019 at the Royal Stoke University Hospital due to the consequences of her Children and Adolescent Mental Health Hospital (“CAMHS”), Huntercombe Hospital, to the Acute Adult Unit at the Harplands Hospital on the 4 November 2019 . He was transferred from a 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. – During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions. It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you NHS ENGLAND AND NORTH STAFFORSHIRE COMBINED HEALTHCARE 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 17/12/2021. 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. The Family Of Sky Louise Rollings; a) b) (mother); and (father); and 2. The Huntercombe Group Limited; and 3. The CQC. I am also under a duty to send the Chief Coroner a copy of your response and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 16/10/2021 Signature Emma Serrano Area Coroner Stoke-on-Trent & North Staffordshire Coroner's Court
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.
Ms Emma Serrano, Area Coroner Stoke-on-Trent and North Staffordshire Coroner’s Chambers, 547 Hartshill Road, Hartshill, Stoke-on-Trent ST4 6HF National Medical Director and Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 20 January 2022 Dear Ms Emma Serrano, Re: Regulation 28 Report to Prevent Future Deaths – Sky Louise Rollings, who died on 9 November 2019 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16 October 2021 concerning the death of Sky Louise Rollings on 9 November 2019. Firstly, I would like to express my deep condolences to Sky’s family. I note the recent inquest concluded Sky’s death was a result of misadventure contributed to by neglect. Following the inquest, you raised concerns in your Report to NHS England as follows: 1. During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult Mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions. 2. It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. In response to your first concern I can confirm that young people are not all automatically transferred at 18 year of age. Where it is feasible for their episode of NHS England and NHS Improvement care to be completed within the CYPMH (or CAMHS) unit safely and quickly, and with subsequent discharge into the community, this is often preferred and supported. I can confirm that NHS England and Improvement (NHSEI) is the responsible commissioner for specialised inpatient services for Tier 4 CAMHS patients up to the age of 18. The regional teams of NHS England and Improvement commission specialised services for inpatient Tier 4 CAMHS provision against the national service specification. The current specification for the type of service where Sky was treated is available here: Discharge and admission planning processes are in place, and someone would not ‘immediately be treated in accordance with the adult provisions’. The development and clinical decision making in a young person’s care plan and discharge plan are considered by the young person’s current Tier 4 CAMHS provider’s clinical team. This includes multi-agency/ professionals e.g. social worker, community mental health services, the young person and their family’s views and again is individualised to each patient’s needs and circumstances. In Sky’s case – discharge planning and involvement of adult acute services and adult social worker and care coordinator commenced 6 months prior to her discharge date on 29 October 2019. It was noted that adult acute or adult PICU provision would need to be considered if a community placement was not able to meet SK’s needs. In response to your second concern, under the Current Mental Health Act 1983: section 131A states that “the patient’s environment in the hospital is suitable having regard to his age (subject to his needs)”. While it allows 16- and 17-year-olds to still be looked after on adult wards occasionally in exceptional circumstances, such as if they need to be admitted as an emergency, under-16s should not be being treated there. The Care Quality Commission (CQC) does not recommend admissions for under 18 years onto adult wards and every under 18 years admission onto an adult ward is reported as a SI. There are safeguarding concerns and implications that need to be taken into consideration in having young people under 18 years and those over 18 years on the same ward, which will usually mean requiring increased observations (which places additional pressure on staffing and can feel restrictive for young people themselves). Subsequently, from safeguarding perspective we would not be recommending inpatients wards 14-25 years of age as there are significant developmental differences between a 14 year old and 25 year old young person that would place vulnerable young people at risk (many of our CYPMH units have a disproportionately tier-4-camhs-general-adolescent-service-specification-v3 - reference to post 18 yrs.pdf high number of young people with autism and other neurodevelopmental needs in addition to their mental health needs). I have however reviewed the Trust response and I can see that they have commenced work with the partners relating to community transformation in social care and third sector CYP support to support the development of a 14-25 Transition (Preparing for Adulthood) service. I further note that the Trust plan for this service to align to the Good Mental Health Services for Young People (Royal College of Psychiatry, 2017) good practice paper. This PFD report will be shared with Mental Health Trusts through the Regional Teams at NHS England and NHS Improvement as well as learning from the Trust plan. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director
Date: 16th December 2021 Dr Consultant Psychiatrist/Interim Medical Director Trust Headquarters Lawton House Bellringer Road Trentham ST4 8HH Emma Serrano, Area Coroner Stoke-on-Trent & North Staffordshire Coroner Stoke on Trent and North Staffordshire Stoke Town Hall, Kingsway, Stoke-on-Trent, ST4 1HH Dear Mrs Serrano Regulation 28 Report – Prevent Future Deaths – Sky Louise Rollings During the course of the inquest for Sky Louise Rollings, 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) During the inquest, evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest, it was established that when a child turned 18, and was a patient on a Mental Health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions. (2) It was accepted that there is no provision; there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. Trust responses to Matters of Concern Above (see appendix 1 for Action Plan) (1) The Trust has initiated a further review of the Transition of Young People to Adult Mental Health Service Policy following the inquest. The review will include the above concerns raised during the inquest relating to the transition from a young person’s inpatient facility to an adult mental health facility (which may include an adult mental health inpatient ward) www.combined.nhs.uk Follow us on Twitter: @CombinedNHS Follow us on Facebook: www.facebook.com/NorthStaffsCombined We are a diverse and inclusive Trust and there is no place in our organisation for discrimination, harassment or personal abuse and the need to ensure appropriate reasonable adjustments are made in line with person centred care and that appropriate monitoring and escalation processes are robust and in place. (2) Whilst the Trust acknowledges there is no in-patient provision for people between the ages of 14-25, as part of the Community Transformation agenda we have commenced work with the partners relating to community transformation in social care and third sector CYP support to support the development of a 14-25 Transition (Preparing for Adulthood) service. This service will seek to align to the Good Mental Health Services for Young People (Royal College of Psychiatry, 2017) good practice paper. The service seeks to improve the continuity of care provided to young people and their families as they undergo transition between services and improve understanding between services regarding thresholds of care and models of care, exploring and understanding the differences of intensity of support for young people and that of adults by ensuring appropriate person centred requirements and improving education/training for adult mental health services. Please do not hesitate to contact me should you need any further information. Yours sincerely Dr Consultant Psychiatrist Interim Executive Medical Director www.combined.nhs.uk Follow us on Twitter: @CombinedNHS Follow us on Facebook: www.facebook.com/NorthStaffsCombined We are a diverse and inclusive Trust and there is no place in our organisation for discrimination, harassment or personal abuse No 1 Health the care of Area of Concern During the inquest, evidence was heard about the differences in the way CAMHS Hospitals and Adult Hospitals Mental approached the patients on their wards. When the hearing evidence during inquest it was established that when a child turned 18, and was a patient on a Mental Health ward, once transferred to an adult Mental they would Health Hospital in treated immediately be accordance with adult the provisions. Action Plan Appendix 1 Identified Action Policy 1.01 – Transition of Young People to Adult Mental Health Services – to be reviewed. To on acknowledging that a person does not become an adult on their 18th birthday. guidance include Lead Completion date 31st March 2022 Assurance Updated section to the Policy in line with the actions raised. Policy will be shared with all in patient areas/community teams. Provide guidance and on making reasonable appropriate line with person adjustments centred care and that ensures monitoring and escalation processes are robust and in place. in Highlight the importance of reviewing the approach to patient care on a case-by-case basis – not simply applying an approach to care based on the person being placed on an adult ward as they have legally reached the age of adulthood now and this is how it is. www.combined.nhs.uk Follow us on Twitter: @CombinedNHS Follow us on Facebook: www.facebook.com/NorthStaffsCombined Adeye We are a diverse and inclusive Trust and there is no place in our organisation for discrimination, harassment or personal abuse
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