Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0128, written 28 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Apr 2022 |
|---|---|
| Reference | 2022-0128 |
| Deceased | Laura Medcalf |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) · Alcohol, drug and medication related deaths |
| 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: The Secretary of State for The Department of Health and Social Care. CORONER 1 I am Alison Mutch, Senior Coroner, for the Coroner Area of 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 3 INVESTIGATION and INQUEST On 18th February 2021 I commenced an investigation into the death of Laura Jane Medcalf. The investigation concluded on the 8th April 2022 and the conclusion was one of Narrative: Died from suicide contributed to by a failure by mental health services to recognise her deteriorating mental health and the increased risk she presented and to take effective steps to reduce the risk. The medical cause of death was 1a Multi organ Failure; 1b Hypoxic Brain Injury;1c Asphyxiation on background of gabapentin toxicity 4 CIRCUMSTANCES OF THE DEATH Laura Jane Medcalf managed her mental health through exercise and controlling her food intake. The onset of Covid-19 restrictions and surgical interventions for her hydrocephalus meant that the routine she had relied on to manage her mental health was not available to her. On 3rd December 2020 after considering taking her own life for a number of weeks Laura Jane Medcalf took an overdose of paracetamol. She was taken to Salford Royal Hospital after she told her family what she had done. On 4th December 2020 she was assessed as requiring a mental health bed. She consented to a mental health in-patient stay but would have been sectioned had she not consented. Shortage of mental health beds meant she was kept at Salford Royal Hospital until moving to a bed on the Medlock Ward on 10th December 2020. She was discharged on 16th December 2020. On 17th December 2020 she was assessed by the home-based treatment team who identified she needed to be re-admitted to the Medlock Ward. Whilst waiting for a bed she went to went to hospital due to concerns about keeping herself safe. She was readmitted to the Medlock Ward as a voluntary patient. She continued to be prescribed medication including gabapentin. She had disclosed that the discomfort from that neurosurgery had impacted her mental health. There was a failure to follow up a referral to the neuro team, this did not contribute to her death. On 16th January 2021 she told staff on the ward she had taken a paracetamol 1 overdose and drunk vodka whilst on the ward. She was taken to hospital for treatment. On 22nd January 2021 she returned to the Medlock ward. On 31st January 2021 she was found in her bed with a There was a failure to complete a Datix incident form in compliance with trust policy. On the afternoon of 9th February 2021, she was found in bed in her room with a . She remained on level 3 observations and her room was searched. A risk assessment completed on 9th February recorded this incident but failed to analyse or explore how this impacted her risk. On the evening of 9th February about 8pm there was a further incident when she was found on checks by staff in her bed with a . Her room was not searched. She was moved to level 2 observations but there was a failure to follow the trust policy in how these observations were implemented or subsequently stopped. On a check approximately 10 minutes later on 9th February 2021 she was again found with a . Her rom was searched again. There was a failure to record these in a risk assessment or to adequately assess how the three incidents reflected a deterioration in her mental health and impacted on the risk she presented or how to mitigate further the risk of carrier bags. On 14th and 15th February 2021, she was declining food according to the food charts. This was not recognised as a potential symptom that could reflect a deterioration in her mental health. On 14th February 2021 she told staff that she had had a day of bad thoughts. There was a failure to explore this or to assess If this presented an increased risk. On 15th February 2021 she told staff she had had a bad day. There was a failure to link this to the disclosure of 14th February, to then explore this disclosure with her or to re-assess the risk she presented. On 17th February 2021 on a level 3 check at about 12:10 am Laura Jane Medcalf was found in her bed in her room with a Attempts were made to resuscitate her and she was transferred to Manchester Royal Infirmary. She died there on 17th February 2021. A post-mortem examination included toxicology. It was found that she had an above therapeutic level of gabapentin in her system. Staff on the ward had failed to identify that she had possession of gabapentin in her room. She had died from a hypoxic brain injury caused by asphyxiation on a background of gabapentin toxicity. A search of her room by GMP also found a table and a possession of. in her dressing gown that staff had not realised she had in her bedside 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 inquest heard that Laura Medcalf was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental 2 health beds. The inquest heard that there is a national shortage of inpatient beds and that this delay is not unusual. 2. The inquest heard that during the period of time that Laura Medcalf was an in- patient on a mental health ward there were significant staffing challenges. Those challenges were part of a national picture of availability of mental health staff. Against this background and in order to keep the ward staffed and fully operational the trust had to move staff from other mental health services; use agency/bank staff and use leadership and management staff to backfill for nursing staff. 3. The evidence before the inquest was that Covid 19 and the measures to deal with it had had a significant impact in a number of respects. In particular that included the impact of lockdown on the mental health of Laura Jane Medcalf. 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, namely by 23/06/2022. 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 Chief Coroner and to the following Interested Persons namely, Metropolitan Borough Council and The Care Quality Commission who may find it useful or of interest. (NOK), Greater Manchester Mental Health, Trafford 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 Alison Mutch HM Senior Corner HM Coroner’s Court Manchester 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
Ms Alison Mutch 25 November 2022
Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Ms Mutch,
Thank you for your letter of 28 April 2022, to the Secretary of State for Health and Social Care, about
the death of Laura Medcalf. 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 Medcalf’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, my officials made enquiries with NHS England (NHSE), the Care Quality
Commission (CQC).
I understand that several actions have been taken following Ms Medcalf’s death. A Root Cause
Analysis was undertaken by Greater Manchester Mental Health NHS FT (GMMH) as a result of Ms
Medcalf's death in line with the patient safety and serious incident process. This did not reveal that
a shortage of beds was a contributory factor in this case. However, patient flow continues to be a
main priority for the mental health system at a local, regional and national level. You may wish to
know that GMMH are addressing these issues through the purchase of independent sector beds,
alongside increased investment in schemes and workforce initiatives to support patient flow. In
addition, system partners continue to support All-Age Mental Health Liaison teams in A&E and the
advisory capacity they offer across Greater Manchester.
You may also wish to note that the Department is investing £150 million for significant improvements
in the mental health estate over the course of the Spending Review (2021). This will be used to
support our NHS Long Term Plan ambitions regarding system capacity and pressure reduction. It
will cover a range of schemes, including non-medical alternatives to admission, step-down
community beds and supported living services.
We are also investing £300 million over this Spending Review to eradicate mental health dormitories
by 2024/25. By 2024/25, over 1200 beds in mental health dormitories across more than 50 sites will
be replaced with single, en suite rooms. Although this may impact bed availability temporarily, it will
support patients by improving their care, safety and sense of dignity.
An additional £116 million was invested in the NHS in 2021/22 to support people to be discharged
safely and appropriately from mental health inpatient units. Improving flow will help ensure beds are
available to those most in need. Major expansion in funding for community mental health services
commenced in all areas in 2021/22, which has been key to managing pressures on beds. As set
out in the NHS Long Term Plan, our aim is to improve community support for serious mental illnesses
to avoid the need for an inpatient admission where possible. We continue to work closely with NHS
England to monitor this.
The Department is also fully committed to attracting, training, and recruiting the mental health
workforce of the future. Through our plans set out in Implementing the Five Year Forward View for
Mental Health1 and Stepping Forward to 2020/2021: The mental health workforce plan for England2,
the Department have expanded and diversified the types of roles that are available.
"Stepping Forward” set out an ambition for 21,000 new posts (professional and allied) across the
mental health system occupied by 19,000 new staff by 2020/21. The 19,000 new staff target has
now been met and as of June 2022 there were 133,573 full time equivalent (FTE) from a baseline of
109,118 in March 2016. This includes only those people who work directly on mental health, across
NHS Trusts, NHS Foundation Trusts and integrated care boards.
In addition to the level of growth set out in “Stepping Forward”, the NHS Mental Health
Implementation Plan 2019/20–2023/243 sets out the need for the mental health workforce to grow
by over 27,000 during this time frame to support the expansion and transformation of NHS mental
health services and give an extra two million people the mental health support they need. The
Department invested £111 million in 2021/22 to grow the mental health workforce towards delivering
these ambitious commitments. You may also wish to note that Health Education England and NHS
England have been working with integrated care systems (ICSs) to confirm plans to 2024 . This will
aim to ensure a system-wide effort to meet the Mental Health Implementation Plan ambition, looking
across service models, supply, retention, and recruitment.
You also raise the matter of Covid-19 measures, including lockdown. The Covid-19 pandemic
required the Government to put a number of unprecedented measures in place, including shielding,
social distancing and local and national lockdowns. We know that the pandemic and these measures
have had, and will continue to have, an impact on the mental health and wellbeing of many people.
That is why we published our Mental Health Recovery Action Plan4 in March 2021, backed by an
additional £500 million for 2021/22, to accelerate our expansion plans in order to address waiting
times for mental health services, give more people the mental health support they need, and invest
in the NHS workforce.
This is on top of the NHS Long Term Plan commitment to increase spending on mental health
services in England by at least £2.3 billion a year by 2023/24.
You will be aware that there will be an independent public Inquiry into the handling of the Coronavirus
pandemic, which is set to begin its work in Spring 2022. The Prime Minister has appointed the Rt
Hon Baroness Heather Hallett DBE as Chair of the Inquiry. The Government is committed to
learning lessons from COVID-19 to inform our preparedness for future pandemics and the
Department will respond openly and transparently and fully consider all recommendations made by
the Inquiry.
On patient safety more widely, you may be aware of recent allegations of mistreatment at the
Edenfield Centre in Prestwich, another hospital that is part of GMMH. This featured on a recent
episode of the Panorama programme, which aired on 28 September.
1 https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf
2 https://www.hee.nhs.uk/sites/default/files/documents/Stepping%20forward%20to%20202021%20-
%20The%20mental%20health%20workforce%20plan%20for%20england.pdf
3 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-
2023-24.pdf
4 https://www.gov.uk/government/publications/covid-19-mental-health-and-wellbeing-recovery-action-plan
In response, NHS England’s National Mental Health Director, Claire Murdoch, wrote to the Chief
Executives of all NHS mental health, learning disability and autism service providers in England
asking them to review the safeguarding of care in their organisations and identify any immediate
issues requiring action now, review how the patient voice is being heard in their organisations and
how it is being acted on, and take steps to tackle and reduce the use of restrictive interventions.
Also, as part of the NHS Patient Safety Strategy, the NHS Long Term Plan commits to a new Mental
Health Safety Improvement Programme, which has set up mental health Patient Safety Networks
covering all regions in England. 47 NHS Trusts and 5 private providers of NHS inpatient services for
people with poor mental health, people with a learning disability and autistic people are being
provided with improvement support by the regionally-based Patient Safety Collaboratives, made up
of NHS providers and commissioners. The Patient Safety Networks have also recruited Trusts to
focus on reducing restrictive practices.
But 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.
Finally, for the workforce as a whole, we have commissioned NHS England to develop a high-level
long-term workforce plan. The plan will look at the mix and number of staff required across all parts
of the country for the whole NHS workforce and will set out the actions and reforms that will be
needed to reduce supply gaps and improve retention. NHS England are engaging with a broad range
of stakeholders in developing this plan and it is due to be completed by the end of 2022
It is unacceptable that this death has happened, and we will take the shared learnings from this case
to push progress forward. 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.
MARIA CAULFIELD MP
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