Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0159, written 12 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jul 2022 |
|---|---|
| Reference | 2022-0159 |
| Deceased | Louise Allen |
| Coroner | Nadia Persuad |
| Coroner area | East London |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Organisation named | North East London 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.
MISS N PERSAUD HER MAJESTY’S CORONER EAST LONDON East London Coroners Court, Adult Learning College, 127 Ripple Road, Barking, IG11 7PB REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref: 14169257 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. , North East London NHS Foundation Trust. Trust Head Office, CEME Centre- West Wing, Marsh Way, Rainham, Essex, RM13 8GQ Sent via email to: , Assistant Director of Integrated Commissioning, London Borough of Waltham Forest, NHS North East London Clinical Commissioning Group, TNW Integrated Care Partnership and North East London Health and Care Partnership, 4th Floor, Unex Tower, 7 Station Street, London, E15 1DA Sent via email to: 1 CORONER I am Nadia Persaud area coroner for the coroner area of East London 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 24th June 2021 I commenced an investigation into the death of Louise Asha Allen, aged 41 years old. The investigation concluded at the end of the inquest on the 5th July 2022. The conclusion of the inquest was a narrative conclusion: Louise Allen took her own life whilst suffering from a mental health disorder. She was 1 recognised as a very high risk to self, but in the months leading up to her death she did not receive the care that was necessary to protect her from the high risk with which she presented. 4 CIRCUMSTANCES OF THE DEATH Louise Allen suffered from bipolar disorder and emotionally unstable personality disorder. She was discharged from hospital following a lengthy admission to hospital in mid-December 2020. She was regarded as a very high risk to self and she required a careful and comprehensive community care-plan. Between February 2021 to June 2021 she did not receive the necessary mental state assessments by her care-co-ordinator; there was no additional support provided to engage her in activities to assist in promoting her recovery. In addition, inaccurate clinical details were on occasion presented to the multi-disciplinary team, resulting in unreliable risk assessments. On the evening of the 12th June 2021 Louise travelled to where she placed herself in front of a train. 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 CONCERN are as follows: Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include: 1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff. 2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts. 3. Care Co-ordinators within the Trust are currently carrying excessive caseloads. 4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators. 5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [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 12 September 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: the family of Louise Allen, the Care Quality Commission and to the local Director of Public Health who may find it useful or of interest. 2 I am also under a duty to send a copy of your response to the Chief Coroner 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 12/07/2022 [SIGNED BY CORONER] 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.
PRIVATE & CONFIDENTIAL
Ms N Persaud
HM Coroner
East London Coroners Service
Adult Learning College
127 Ripple Road
Barking,
IG11 7PB
Your ref: 14169257
Trust ref: 1106 AP CR
Acting Chief Executive
Trust Head Office
West Wing
CEME Centre
Rainham
Essex
RM13 8GQ
10 August 2022
T:
By email only to:
and
Dear Madam
Re: Inquest touching upon the death of Louise ALLEN
I refer to your letter dated 18 July 2022 and the enclosed Regulation 28 report, issued in respect
of your concerns regarding the risk of future deaths.
Concerns
At the conclusion of the hearing into the death of Louise Allen, you expressed concern on the
matters below:
1. There is a need within the Trust for better continuity of care. There are not enough care
co-ordinators to ensure that continuity of care is provided. There are high turnovers of
staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The
evidence heard that the pay within North East London Foundation Trust is not comparable
to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has
been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under
recruited in terms of the clinical need for care co-ordinators.
Acting Chair:
Acting Chief Executive:
www.nelft.nhs.uk
We have taken the following actions in relation to your concerns:
Need for better continuity of care, not enough care co-ordinators to ensure continuity of
care is provided, and high turnover of staff.
The service continuously recruits temporary staff, through the Trust’s temporary staffing service
until all positions are permanently recruited to.
Temporary staffing has been advised to prioritise Mental Health posts and to use off-framework
agencies to support retaining locum support, and consistency to manage short term vacancies.
A NELFT training programme has been developed for band 5 staff to help them develop the
skills and competencies to take up the role of care coordinator at band 6 level. This will
constitute an intensive and supportive career development programme designed to attract
recently qualified staff who have the potential to progress rapidly and will also help with staff
retention in the community recovery service.
The trust has invested 2.5 million pounds to support Nursing, Allied Health Professions and
Psychological Professions recruitment initiatives which includes international recruitment.
Efforts to make the post of care co-ordinator more attractive, and that pay at NELFT is at
least comparable to other NHS Trusts.
NELFT has programmes in place to encourage staff to work in the organisation; the Trust has
used non-recurrent funding to recruit additional staff to manage the real time increase of referrals
and acuity of patients, following the pandemic. All new starters’ salaries are matched to their
previous employment, so they do not lose out on their pay when they join NELFT. There is also
a staff wellbeing service in place which is available to substantive and locum staff. In addition,
the Trust is working to understand how staff can be supported through cost-of-living issues.
The Trust is undertaking a programme of mental health transformation, which once fully
implemented will enhance the service offered to patients. Peer support workers have been
given additional roles, with a focus on enhanced training in order that they can share their lived
experiences with patients they manage. The Trust is re-designing care coordinator posts to
increase the support available for professional development. Furthermore, the Trust continues
to use Trust-wide work streams to have a zero-nursing vacancy; to use rolling advertisements
to recruit and retain staff; utilise international recruitment to attract more professionals to work
at NELFT; and to consider the use of financial incentives to attract and retain staff.
Reducing the case loads of care coordinators, to ensure they are not excessive.
A recent quality audit of staff caseloads carried out on 19 July 2022 showed a reduction in care
coordinator caseload from 27-30 patients per care coordinator to 19-27 patients. There is a
further audit planned on 19 August 2022 to review the caseload numbers per care coordinator
In the meantime, the Trust is introducing a Management and Supervision Tool (MaST) to
support staff and their managers to ensure care coordinator caseloads are manageable and
that appropriate supervision and support are in place; this is anticipated to be fully operational
by December 2022.
No commensurate increase in number of care coordinators to match the increased
number of referrals to the service.
Acting Chair:
Acting Chief Executive:
www.nelft.nhs.uk
A Quality Summit for the Waltham Forest Community Recovery Team was launched in July
2022.The purpose of the summit was to agree key quality priorities to improve patient/staff
safety and quality of service delivery in the Waltham Forest Directorate. The focus will be on
mental health services following feedback from Coroner Regulation 28 reports and learning
from Serious Incidents. It is expected that actions will be developed and implemented and will
include service re-design based on the level of demand and need, following the Quality
Summit. Recommendations from staff and service users will inform the actions to be taken.
Trust-wide initiatives will also be considered, including system wide consultation within the NE
London Integrated Care System to strategically consider the needs of the population and the
associated risks.
Despite over-recruitment of care coordinators in financial budgets, the service is under-
recruited in terms number of care coordinators.
The community mental health transformation programme will provide a better skill mix that will
reduce the pressure on the care coordinator role. 8 additional Band 6 Community Psychiatric
Nurses are being recruited to meet increased workload.
The NELFT Waltham Forest leadership team continuously reviews the needs and risk of the
service. Additional staff will continue to be placed in the service to manage the need and risk,
efforts are made at Trust executive and North East London system wide level to review the
resource and staffing levels deployed into the service.
I would like to take this opportunity to thank you for raising your concerns as part of this inquest.
We find learning from inquests extremely valuable and are very grateful for your comprehensive
investigation, which benefits not only the families of the deceased, but also the Trust and its
service users.
I trust that the above and the attached action plan will reassure you that the Trust has taken this tragic
death very seriously indeed, and that it reflects our commitment to improve care quality and patient
safety.
If I can further assist, please do contact my office on
Yours sincerely
Acting Chief Executive
Enc: Action Plan
Acting Chair:
Acting Chief Executive:
www.nelft.nhs.uk
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