Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0038, written 4 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2022 |
|---|---|
| Reference | 2022-0038 |
| Deceased | Joy Burgess |
| Coroner | Chris Morris |
| Coroner area | Greater Manchester South |
| Category | Mental Health related deaths · Suicide (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths · Other related deaths |
| Organisation named | Pennine Care 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt. Hon. Sajid Javid, Secretary ofState for Health and Social Care 1 CORONER I am Chris Morris, Area Coroner for Greater Manchester (South). 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 htt12://www.legislation.gov.uk/uksi/20 l 3/ l 629/12art/7/made 3 INVESTIGATION and INQUEST On 25th June 2021, Anna Morris, Assistant Coroner, opened an inquest into the death ofJoy Burgess who died on 9th June 2021 aged 56 years. The investigation concluded at the end of the inquest which I heard on 4th February 2022. A post-mortem examination undertaken by Pathologist, determined Ms Burgess died as the result ofmultiple injuries. Consultant By way of conclusion, I recorded that Ms Burgess died as a consequence of suicide. 4 CIRCUMSTANCES OF THE DEATH Joy Burgess died from multiple injuries sustained as a consequence of . Ms Burgess had a long history of complex mental health difficulties and had been under the Community Mental Health Team. In addition to being prescribed medication, Ms Burgess was on a lengthy waiting-list to access psychological therapies. In May 2021 , Ms Burgess's mental health deteriorated with her developing an increasing array of depressive symptoms, anxiety which was providing difficult to manage in the community, and thoughts of self-harm. She was admitted to hospital as a voluntary patient, but took her own discharge a number ofdays later. Ms Burgess disclosed to staff that this was because she found the ward environment was busy and extremely noisy. Ms Burgess described being disturbed by the screams ofsome ofthe patients, and considered being on the ward was making her feel worse. Upon leaving the ward, Ms Burgess was followed-up by her Care Co-Ordinator and the Home Treatment Team. 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 the mental health ward environment could be 'chaotic' (in the words ofone Consultant Psychiatrist) and that resources and demands on inpatient beds were such that staff were not always able to care for patients in a suitable environment. It is a matter of concern that mental health patients are, on occasion, cared for in an environment which is very obviously not conducive to recovery. 2. The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 1st May 2022. 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 ChiefCoroner and to behalf of the family and Pennine Care NHS Foundation Trust. on 2 I have also sent a copy ofmy report to Tameside Metropolitan Borough Council, the Care Quality Commission, and Greater Manchester Health and Social Care Partnership, all ofwhom I consider may find the report useful or of interest. 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 ofthis report to any person who he believes may find it useful or ofinterest. You may make representations to me, the coroner, at the time ofyour response, about the release or the publication ofyour response by the ChiefCoroner. 9 Dated: ~ ~ Signature: Chris Morris H reater Mane ea Coroner, t~South.) 3
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 Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU 09 November 2022 Our Ref: PFD – 1392892 Chris Morris Area Coroner for Greater Manchester (South) Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris, Thank you for your correspondence of 4 February 2022, to the then Secretary of State for Health and Social Care, Sajid Javid, regarding the death of Joy Burgess. I am replying as Minister with responsibility for Mental Health, and thank you for the additional time allowed. I would like to begin by offering my deepest condolences to the family and loved ones of Mrs Burgess. Your report raises important concerns regarding the quality and suitability of care for those suffering from mental health problems, and long waiting times for psychological therapies. It is, of course, vital that we take learnings, where they are identified, to improve the NHS care, and I am grateful to you for bringing these matters to my attention. In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC). I am also informed that Pennine Care NHS Foundation Trust (PCFT) have produced an investigation report, in line with the NHS Serious Incident Framework, and have provided evidence at the inquest, and that the CQC has accepted the findings of the report. We recognise the importance of providing an environment that feels safe and comfortable for people receiving treatment in mental health inpatient care. I understand that in their Concise Investigation Report, the Trust acknowledged that Ms Burgess’s experience on the Taylor ward fell short of the expected standard. You may wish to note that the Government is committed to upgrading the physical environment for inpatient mental health care, and we are already taking steps to modernise inpatient environments and improve patient experience. We are investing more than £400 million over the 4 years up to 2024/25 to eradicate dormitory accommodation from mental health facilities to improve From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU the safety, privacy and dignity of patients suffering with mental illness. In addition, we are investing £150 million for significant improvements to the mental health estate, including investing in NHS mental health facilities linked to accident and emergency departments, enhancing patient safety in mental health units, and new mental health ambulances. You noted that Ms Burgess was on a lengthy waiting-list to access psychological therapy at the time of her death and were concerned that other patients are continuing to wait significant lengths of time for care. The pandemic has had an impact on the mental health and wellbeing of many people, which has caused increased demand for mental health services. In order to help address this, we provided an extra £500 million in 2021/22 to accelerate our expansion plans and address waiting times for mental health services, which will provide more people with the mental health support they need and invest in the NHS workforce. This funding included £110 million to expand adult mental health services - including talking and psychological therapies, implementing the community mental health framework, investment in crisis services and maintaining the delivery of the 24/7 urgent mental health helplines stood up earlier in the pandemic, as well as additional investment in suicide prevention programmes. The NHS Long Term Plan committed that, by 2023/24 we will invest almost £1 billion extra in community mental health care for adults with severe mental illness. You may also wish to know that work is also ongoing to expand and improve mental health crisis care provision. This includes improving the operation of all age 24/7 crisis lines, crisis resolution home treatment teams, and mental health liaison services in A&E departments. With regards to those people with more complex mental health needs, who are waiting for treatment, NHS England consulted in 2021 on the potential to introduce five new waiting time standards as part of its clinically-led review of NHS access standards. The proposals included: • Patients referred from Accident and Emergency should be seen face to face within one hour, by mental health liaison or children and young people’s equivalent service • For a ‘very urgent’ referral to a community based mental health crisis service, a patient should be seen within four hours from referral, for all age groups • For an ‘urgent’ referral to a community based mental health crisis service, a patient should be seen within 24 hours from referral, across all ages • Children, young people and their families/carers presenting to community-based mental health services, should start to receive care within four weeks from referral; and From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU • Adults and older adults presenting to community-based mental health services should start to receive help within four weeks from referral. NHS England published the outcomes of its consultation in February 20221, and we are now working with them on the next steps. I hope this response reassures you that the government and the NHS take mental health seriously and that action is being taken to address the quality and timeliness of care. Kind regards, MARIA CAULFIELD 1 https://www.england.nhs.uk/2021/07/nhs-england-proposes-new-mental-health-access-standards/
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