Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0094, written 25 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Mar 2022 |
|---|---|
| Reference | 2022-0094 |
| Deceased | Natalie Turner |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Alcohol, drug and medication related deaths · Other related deaths · Community health care · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Lancashire & South Cumbria NHS Foundation Trust |
| 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. Maria Caulfield MP Parliamentary Under Secretary of State (Minister for Patient Safety and Primary Care) Department of Health & Social Care Ministerial Correspondence and Public Enquiries Unit 39 Victoria Street London SWlH 0EU United Kingdom 2. Board of Governors [Chair], British Association for Counselling and Psychotherapy (BACP): 15 St John's Business Park, Lutterworth, Leicestershire LE17 4HB, United Kingdom bacp@bacp.co.uk 1 CORONER I am Alan Anthony Wilson Senior Coroner for Blackpool & Fylde 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.le gislation .gov.uk/ ukpga/ 2009/ 25/ schedule / 5/paragra ph/7 http://www. le gislation .gov. u k/ u ksi / 2013/ 1629/part/7/ made 3 INVESTIGATION and INQUEST The death of Natalie Melissa Turner on 27.10.20 at her home address was reported to me and I opened an investigation which concluded by way of an inquest held on 20th to 23 rd March 2022. I determined that the medical cause of Natalie's death was 1 a Laxative abuse In box 3 of the Record of Inquest I recorded as follows: Natalie Turner had for a number of years been abusing laxatives as part of a long - standing eating disorder. She had hidden the true extent of that abuse secret until November 2019. After being admitted to hospital on 05/11/19 in an acute condition, she needed to be provided with parenteral nutrition, and once stabilised she was discharged home on 14/11/19, only to return to hospital on 19/11/19 after ingesting more laxatives. Again stabilised, she returned home on 09/12/19 with a view to receiving care from the Home Treatment Team that was to involve regular - assessment, and weekly physical monitoring including blood tests and weight checks. Her condition did not initially raise significant concerns. On 03/01/20 she was discharged from the Home Treatment Team but it was envisaged that she would continue to receive regular physical monitoring. Such monitoring did not happen, in part because of Natalie's reluctance to engage with this, but also because the procedure usually followed at her GP surgery in order to encourage patients to undergo such monitoring was inadvertently not fully followed. This went unrecognised for a number of months. Throughout 2020, Natalie participated in some privately funded counselling sessions. By around April 2020, she had divulged to her Counsellor that she was ingesting laxatives in significant quantities. My mid - June 2020, her Counsellor was concerned for Natalie's welfare but preferring to respect Natalie's privacy she did not feel it appropriate to raise her concerns with medical professionals or Natalie's Husband. This was an opportunity to provide some urgent medical attention. Over subsequent months, Natalie continued to abuse laxatives. By 26/10/20, she was noticeably unwell with vomiting and diahorrea. After her Husband provided here with a drink of water at shortly after 3 am on 27/10/20 when Natalie reported that she remained unwell, she was found unresponsive in her room at around 7.15 am later that morning. A post mortem examination confirmed that she died from the effects of laxative abuse. In box 4 ofthe Record of Inquest I determined that Natalie died due to: MISADVENTURE. 4 CIRCUMSTANCES OF THE DEATH In addition to the contents of section 3 above, the following is of note: 1) Natalie had an eating disorder, ultimately diagnosed in November 2019 as Bulimia Nervosa. For many years, she had been ingesting large quantities of laxatives as a means of losing weight/ maintaining a low weight. She had managed to keep this a secret from her family. 2) By November 2019, the impact of the laxative abuse left her requiring urgent medical attention in hospital. Her BMI reading was under 14, and laxatives had contributed to significant electrolyte imbalance. Her condition only improved following a period of parenteral nutrition. 3) Once stabilised, and then discharged from hospital, she was to receive treatment in the community. This was to include physical monitoring, and psychological work consisting of cognitive behavioural therapy [for which there was a waiting list and this was unlikely to commence for a number of weeks]. 4) Natalie did not receive the physical monitoring she required, in part because she did not wish to engage with it. A notable aspect of her condition was a clear tendency to do what she could to avoid, or at least restrict, any scrutiny by medical professionals. As far as she was concerned, when she was in hospital medical professionals were able to maintain her weight and/ or help her to necessarily gain some weight, and she was rendered unable to continue with taking laxatives whilst in a hospital setting. This apprehension about contact with medical professionals was not limited to hospitals because she clearly sought to minimise contact with GPs in the primary care setting too, because attending a consultation with a GP could in her eyes lead to a return to hospital. 5 CORONEWSCONCERNS 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 send the report: There are two MATTERS OF CONCERN are as follows. - 1. The first issue I raise with Parliamentary Under Secretary of State (Minister for Patient Safety and Primary Care), Department of Health & Social Care. • The inquest received some helpful evidence from a GP, Dr , of the Ash Tree House Surgery, Kirkham. In court, I acknowledged the response of that surgery to Natalie's death which I have found to be thorough, open and constructive, and a genuine attempt to minimise the prospect of a recurrence in the future. Dr explained that notwithstanding her considerable experience as a GP, General Practitioners do not receive specific guidance in relation to eating disorders, which are often very complex in nature. • It seemed to me that GPs can often find themselves in a difficult position when deciding how to approach dealing with a patient who has an eating disorder, but the situation is all the more challenging when the patient is unwilling to engage with medical professionals and accept treatment which is clearly necessary. Many of these patients ostensibly have capacity to make their own decisions, yet given the nature of their eating disorders may go on to make decisions that are not in their own interests. What the GP can and should do is often unclear. • The number of patients affected is not insignificant: indeed, the inquest heard that this one local surgery had recently identified thirteen of their patients were facing challenges relating to an eating disorder. GPs can resort to the current mental health legislation, MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guidance, and NICE (Eating Disorders Recognition and Treatment) guidance which offers some assistance, but it seems to me that in the absence of guidance which focuses on eating disorder patients and what can be done when a patient is not engaging with treatment, GPs are often left unsure about how to help these patients, and in the absence of some guidance on this issue patients may go without treatment and with potentially fatal consequences. • In response to Natalie's death, the Lancashire & South Cumbria NHS Foundation Trust has also responded in a constructive manner and have demonstrated a clear plan to avoid a repetition. This response has included the creation of new posts within the Trust who local GPs will be able to access for guidance and these include a Consultant Dietician and a Consultant Nurse, and hopefully local GPs make use of this new assistance, but this is not always the case elsewhere in the country. 2. The second issue I raise with the British Association for Counselling and Psychotherapy (BACP): • The inquest heard from a BACP Accredited Counsellor, with whom Natalie shared some 63 counselling privately funded counselling sessions between January and October 2020. • BACP guidance includes a set of core principles which ought to guide counsellors, and the guidance makes clear that in exceptional circumstances the need to safeguard clients from serious harm "may require practitioners to override a commitment to make a client's wishes and confidentiality the primary concern". The guidance makes clear that a breach of confidentiality may be justified. • The Counsellor had developed a good therapeutic relationship with Natalie, but in my judgement she felt unduly constrained by the wishing to avoid breaching Natalie's confidence, despite she herself having formed the view given what Natalie was disclosing to her about the extent of her ongoing laxative abuse she was at risk of self harm and of dying. These circumstances were exceptional, it is hard to think of a clearer example where to disclose her concerns to others would have been justified but she preferred not to because she did not feel she could betray her confidence . This was despite having regular discussions with her supervisor, and knowing that Natalie was not accessing the medical monitoring that she needed from her GP. • The Counsellor explained in court that she personally has not knowingly counselled an eating disorder patient before. The potential complexities of these conditions were not fully appreciated. • Patients with eating disorders will commonly prefer to avoid contact with mainstream medical care and treatment, and their families. It follows that such patients may be attracted to discussing their condition privately with a private counsellor. • Although the therapeutic relationship between counsellor and patient is fundamentally important, as the BCAP guidance makes clear there are occasions when a breach of confidentiality is justifiable. Counsellors who .___...,________begin a course of therapy with an eating disorder patient need to appreciate that refraining from breaching confidentiality may well mean the patient goes without necessary and potentially life-saving care and treatment. Even if patients try to reassure counsellors that they are seeking medical help elsewhere, such claims may well not be credible because these patients may be claiming they are being treated as a distraction. • The Counsellor informed the court she did not have the benefit of guidance on eating disorders. More information may have highlighted the particular risks eating disorder patients may pose, particular as regards whether to breach confidentiality or not. In the absence of such guidance, I am concerned that there is a risk that vulnerable patients - who may in fact benefit from a disclosure by their counsellor -will miss out on necessary and potentially life - saving treatment. • Whilst acknowledging that on the BACP website [www.bacp.co.uk], within a section headed "Events & resources", there is a series of articles which explore some of the issues eating disorders may pose for counsellors, the Counsellor who gave evidence at Natalie's inquest did not appear to be familiar with these articles. This arguably reinforces the need for this subject to be raised with counsellors in a more targeted way. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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. Given the approaching holiday period I have extended this period to Friday, 10th June 2022. I, the coroner, may extend the period further. 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: [Natalie's Husband] • • Lancashire & South Cumbria NHS Foundation Trust • Ash Tree House Surgery, Kirkham, Lancashire • Blackpool Clinical Commission Group/ Fylde & Wyre Clinical Commissioning Group • , Medical Director and Director of Education Standards, General Medical Council 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 25/03/2022 Signature__ ~ Alan Anthony Wilson Senior Coroner Blackpool & Fylde ~ - - - - - - - - -
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.
Alan Anthony Wilson Senior Coroner Blackpool and Fylde Coroners PO Box 1066 Corporation Street Blackpool FY1 1GB 6 May 2022 Dear Mr Wilson Re: the late Natalie Melissa Turner I am writing to you in response to the Regulation 28: Prevention of Future Deaths Report which was received from your office on 28th March 2022. I know that you will share a copy of this response with Natalie’s family, and I would first like to express my sincere condolences for their loss. Every death of a client is a tragedy and the safety of those in receipt of counselling and psychotherapy is my absolute priority. We welcome the opportunity to respond to the concerns you raise which are of utmost importance to our organisation, our members and their clients. You expressed concern, following evidence heard at the inquest about several aspects of the private counselling that Natalie received from a BACP accredited member: • • • That despite BACP’s guidance about when it is justified to break confidentiality the counsellor was unduly constrained from doing so to preserve the therapeutic relationship when in this instance breaking confidentiality might have saved Natalie’s life That clients with complex eating disorders might be at particular risk given their reluctance to engage with mainstream medical professionals or their families, despite the fact that medical intervention can keep a client safe That the counsellor had no experience of working with eating disorders which can be complex and potentially life threatening and that there did not seem to be much guidance from BACP on eating disorders In response to your report, we have conducted a thorough review of our member resources relating to confidentiality and when to breach it (including safeguarding and duty of care), working within own limits of competence and guidance on eating disorders specifically. These are detailed in the attached spreadsheet under three themes. You will see that we have also indicated where these are open access (to anyone visiting our website), where members have access as part of their membership subscription (a very substantial body of guidance), and where additional resources can be found if a member subscribes to the CPD hub for an additional £25 per year. Many of these resources will not have been accessible to you. We also offer an Ethics Service which is freely available to members if they have any ethical queries. This service is staffed by a dedicated team who offer access to support, guidance and expertise especially regarding ethical dilemmas which often relate to boundaries, confidentiality and safeguarding issues. The service includes options to book a telephone session with one of our ethics officers and for supervisors to book an appointment with a specialist ethics consultant. We do not know if the therapist or their supervisor availed themselves of these member resources or the additional Ethics service. In terms of the specific concerns relating to this case we would like to offer the following observations: Working with eating disorders can be a complex area of practice. The level of knowledge and skill that the therapist needs will depend on the severity of the issues and a full consideration of the client’s individual circumstances including the immediate and on- going level of risk and self-harm. This can be on a wide spectrum especially given that disordered eating is often a behavioural response to an individual’s situation which may or may not put the client at immediate risk. In addition, clients don’t always divulge an eating disorder at the outset of therapy which means that conducting a risk assessment can be difficult. Working with complex and severe eating disorders does require specialist training which not all therapists have acquired within core training or subsequent training. However, there is no doubt that it is the therapist’s responsibility to recognise their own limitations and consult with their supervisor to determine whether or not they have the right skills to continue working with a client and/or whether a referral to specialist services, or additional specialist support is needed. These can be difficult judgements. The BACP Ethical Framework makes it very clear that therapists must work within their limits of competence and keep their skills and knowledge up to date (Ethical Framework Commitment to Clients clause 2). As a professional body rather than a training body we can and do offer guidance on specific client issues such as eating disorders and set standards for accredited courses, but we don’t directly deliver the training or monitor individual competence in specialist areas. We are, however, very clear that members should not work outside their limits of competence. We offer considerable amounts of guidance, legal, ethical and practical, on when and how to make decisions about when to break confidentiality as this is a key dilemma for therapists. As you helpfully observe this can be a very difficult decision especially when one possible outcome is the breakdown of the therapeutic relationship which may be the only trusting relationship the client has because of the nature of their difficulty. Part of contracting with a client at the outset of therapy (again we have a lot of guidance on this) means being very clear about when and under what circumstances the therapist would break confidentiality. This is particularly important when working with clients who are at high risk of self-harm or suicide. Where confidentiality may need to be broken the therapist is expected to go through an ethical decision-making process with support and guidance from their supervisor and involving the client where possible. What is not clear however, is whether breaking confidentiality would have saved Natalie’s life given that her situation was already known to her GP and specialist medical services and known to her partner. We will continue to keep our guidance and resources under review and to take every opportunity to highlight the critical importance of the professional points and draw them to our members’ attention through our different channels of communication which include direct member bulletins, our Therapy Today magazine which has regular features on these issues, our website and at our member events including our ‘working with’ days which can spotlight specific practice or presenting issues. In that respect we want to thank you for the opportunity to respond to the important issues you raise. Once again, we deeply regret that Natalie’s life was not saved. Yours sincerely Chair of BACP Enc
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU 17th January 2023 Alan Anthony Wilson Senior Coroner Blackpool & Fylde Coroners PO Box 1066, Corporation Street Blackpool FY1 1GB Dear Mr Wilson, Thank you for your letter of 28 March 2022 about the death of Natalie Melissa Turner. I am replying as Minister with responsibility for Mental Health and thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Turner’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, Departmental officials have made enquiries with NHS England as well as the relevant regulator in this instance, the Care Quality Commission. I note that a copy of the British Association for Counselling and Psychotherapy’s (BACP) response to the report was shared with you on 10 May 2022. I, the Department, and partnered health bodies at both a national and local level, take the report’s concerns very seriously. Deaths like these should not happen, which is why improving eating disorders services and treatment is a key priority for the Government and a vital part of our work to improve mental health services. Your report raises important concerns regarding eating disorder treatment and shared learning across the health system. Following the Parliamentary and Health Service Ombudsman (PHSO) report ‘Ignoring the alarms: how NHS eating disorder services are failing patients’, regarding the tragic death of Averil Hart, the Department has been working with NHS England, Health Education England, the General Medical Council (GMC), the National Institute for Health and Care Excellence (NICE) and the Royal College of Psychiatrists through a delivery group to address the recommendations. We understand the importance of working with such partners and remain committed to delivering improvements for this vulnerable group. Regarding your matter of concern on guidance for general practitioners (GPs) on eating disorders, we agree that doctors should have the necessary knowledge and experience of mental health to assess patients holistically, considering the individuals’ physical, social, and psychological needs. GPs are responsible for ensuring their own clinical knowledge remains up-to-date and for identifying learning needs as part of their continuing professional development. This activity should include taking account of new research and developments in guidance, such as that produced by NICE, to ensure that they can continue to provide high quality care to all patients. For newly qualified doctors, we know that the GMC has been working with stakeholders to improve recognition and treatment of eating disorders. The GMC’s Outcomes for Graduates includes that newly qualified doctors must illustrate their understanding of safe management and referral of patients with mental health conditions, including eating disorders. The GMC has also commissioned the Academy of Medical Royal Colleges to work with medical colleges on curricula content, aiming to ensure high standards in core clinical areas. As a priority, the first area being covered is eating disorders. Similarly, to practice as a GP in the UK, GP trainees must undergo 3 years of specialty training (after their foundation years) in which they must demonstrate competence across the GP curriculum, which includes a focus on mental health, including eating disorders. Further, GPs continue their professional development throughout their career. All UK registered doctors are expected to meet the professional standards set out in the GMC Good Medical Practice. In 2012, the GMC introduced revalidation, which supports doctors in regularly reflecting on how they can develop or improve their practice, gives patients confidence doctors are up to date with their practice and promotes improved quality of care by driving improvements in clinical governance. Wider training offers are also available to GPs, including the Royal College of General Practitioners online training course, which helps them to assess, manage and monitor patients affected by eating disorders, including knowing when to make referrals. Similarly, Health Education England are developing training for primary care staff and others who have contact with people with an eating disorder. Beyond this, through the PHSO delivery group, NHS England is working with Health Education England and other partners to procure training courses that will increase the capacity of the existing specialist workforce, to allow them to provide evidence-based treatment to more people. The Department will continue to support this work to progress against key actions, including ensuring better awareness of eating disorder training and continuing professional development. We also recognise the work of external partners, such as Beat, to push forward better training in medical courses and this was the necessary focus of Eating Disorder Awareness Week this year, which we supported and will continue to support as a Department. The Secretary of State for Health and Social Care at the time, Sajid Javid, endorsed a training package developed by Beat, in partnership with Health Education England and NHS England. This training was to support medical students and foundation doctors to identify and respond to a patient with a possible eating disorder. To ensure good clinical practice, NICE guidance provides recommendations for professionals working with individuals who suffer from eating disorders.1 This states that health, social care and education professionals working with people with an eating disorder should be trained and skilled in managing issues around information sharing and confidentiality, safeguarding and working with multidisciplinary teams. As stated previously, GPs are responsible for ensuring that they understand and adhere to NICE guidance. Additionally, ‘Medical Emergencies in Eating Disorders: Guidance on Recognition and Management’ was published by the Royal College of Psychiatrists on 19th May 2022 to support clinicians with early identification and treatment for those with eating disorders. Its aim is to avoid preventable deaths, with an emphasis on medical management across physical 1 https://www.nice.org.uk/guidance/ng69 and psychiatric care. It replaces ‘Management of Really Sick Patients with Anorexia Nervosa’ (MARSIPAN) guidance, which had previously been available. We recognise that eating disorders have some of the highest mortality rates of any mental health disorder and that appropriate monitoring of anorexia nervosa patients by primary or secondary care providers is vital. Under the NHS Long Term Plan, we are committed to ensuring a more integrated service across primary and secondary care for people with severe mental illnesses, including eating disorders, and to giving 370,000 adults with severe mental illness greater choice and control over their care and support them to live well in their communities by 2023/24. To support improvements in mental health care more generally, including eating disorder care, we remain committed to expanding and transforming mental health services in England and to investing an additional £2.3 billion a year in mental health services by 2023/24. This investment has already begun, with all Integrated Care Systems (ICSs) receiving funding to transform adult community mental health services, including eating disorders, with the expectation that all ICSs will have transformed services in place by 2023/24. The Department acknowledges the importance of this funding and adherence to adult eating disorder patient care guidance, to ensure the highest standards of care. NHS England’s work continues to highlight to systems the importance of early intervention services, as well as ongoing medical monitoring and ensuring access to care in the right place, and at the right time. I know there is much more to do to improve the experiences and outcomes for people needing support with their mental health. The Government launched a public call for evidence on what can be done across government in the longer term to support mental health, wellbeing and suicide prevention. The call for evidence closed on 7 July 2022 and we are currently analysing over 5,000 responses received. It is unacceptable that this death has happened, and we will take the shared learnings from this case to push progress forward. The Department takes the matters raised in this report seriously and will continue to engage on progress, in particular via the PHSO Delivery Group. I hope this reply helps to reassure you that partners across the health system are working to make improvements on the basis of this report to prevent this happening in future. Thank you for bringing these concerns to my attention. Kind regards, MARIA CAULFIELD
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