Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0172, written 9 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jun 2022 |
|---|---|
| Reference | 2022-0172 |
| Deceased | Shirley Moloney |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Mental Health 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.
MISS N PERSAUD HER MAJESTY’S CORONER EAST LONDON EAST LONDON CORONERS, ADULT LEARNING COLLEGE, 127 RIPPLE ROAD, BARKING, IG11 7PB REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref: 10342061 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ministerial Correspondence and Public Enquiries Unit, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU Email: 2. , National Medical Director, The National Quality Board, NHS England Email: 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 the 5 January 2021 I commenced an investigation into the death of Shirley Alice Moloney. The investigation concluded at the end of the inquest on 26 May 2022. 1 The conclusion at the end of the inquest was that Mrs Moloney had died from natural causes. There were some concerns however that her underlying mental health diagnosis had been overlooked in the months leading up to her death. 4 CIRCUMSTANCES OF THE DEATH Mrs Moloney suffered from long standing paranoid schizophrenia. In more recent years, she also suffered from hiatus hernia, Barretts’s oesophagus and severe frailty (very low BMI from at least 2019). She was admitted to a care home in April 2019. Mrs Moloney suffered from periods of mental distress, with psychotic symptoms. Mrs Moloney received anti-psychotic medication, but did not receive any care from the community mental health team after April 2020. In December 2020, there was a clear deterioration in her clinical state and she was deemed to be near to the end of her life. Anticipatory (palliative care) medication was prescribed for her. On the 9 December 2020 she suffered three vomits in her care home. She was not administered anticipatory medication to relieve her symptoms at this time. In the early hours of the 10 December 2020, Mrs Moloney was found to be unresponsive in the bedroom of her care home. The emergency services were called and a paramedic pronounced her life extinct on scene. It is likely that she died as a result of aspiration pneumonia. There is no evidence that her death was rendered unnatural, due to any lack of care. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: (i) (ii) (iii) (iv) (v) Mrs Moloney suffered from paranoid schizophrenia. There was evidence of her mental state deteriorating in the months leading up to her death. Her mental health deterioration is likely to have impacted upon her physical health deterioration, but she was not under the care of community mental health services in the last nine months of her life. The inquest heard that older age psychiatric teams are very poorly resourced, nationally. This is compounded by an absence of adequately trained staff, to address mental health in residential home settings. The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs. Once discharged from an older age community psychiatry team, it can take a very long time to access the teams again. These delays can act as a deterrent to GPs in referring patients to community mental health teams. The inquest heard that mental health concerns can often be overlooked towards the end of life. Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined. Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses. They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes. As mental health and physical health are so closely inter-linked, the lack of older adult psychiatry resource for elderly patients, gives rise to a risk of future deaths. 6 ACTION SHOULD BE TAKEN 2 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 4 August 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 am sending a copy of my report to the Chief Coroner, to the family of Mrs Moloney, the CQC, the local Director for Public Health and to the other interested persons to the inquest. The report is also being copied to the Royal College of Psychiatrists and the British Geriatrics Society. 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 9 June 2022 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 1 December 2022 Nadia Persaud East London Coroners Adult Learning College 127 Ripple Road Barking IG11 7PB Dear Ms Persaud, Thank you for your letter of 9 June 2022 about the death of Shirley Alice Moloney. I am replying as Minister with responsibility for Mental Health and I thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Moloney’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 and the Care Quality Commission (CQC). Whilst there was no evidence that a lack of care contributed to Mrs Moloney’s death, we recognise the areas of concern you have identified that could contribute to future deaths. We are committed through the NHS Long Term Plan to offering more NHS support in care homes to ensure there are strong links between care homes, local general practices and community services. You have raised concerns around the resourcing of older age psychiatric teams. We recognise the need to increase capacity in NHS mental health services, including community mental health services for older adults, due to the increasing demand for services. The mental health workforce increased by 5,900 full-time equivalent staff in December 2021 compared to December 2020, and by over 11,800 compared to December 2010. However, we know there is more to do to ensure we have sufficient numbers of healthcare staff to deliver our aims for high quality, accessible mental health services for all ages. We therefore aim to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023/24 (compared to 2019/20). Furthermore, through the NHS Long Term Plan, we are investing at least £2.3 billion additional funding a year to expand and transform mental health services in England by 2023/24. This will enable an extra two million people to be treated by NHS mental health services by 2023/24. This includes new integrated community models, giving 370,000 adults and older adults with severe mental illness greater choice and control over their care and support to live well in their communities by 2023/24. We are also committed to setting clear standards for patients requiring access to community mental health treatment. NHS England has consulted on the potential to introduce five new waiting time standards as part of its clinically led review of NHS Access Standards. These include a proposal that 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 that consultation in February, and we are now working with them on the next steps. With regard to your concerns around a lack of adequately trained staff in care homes, and a lack of establishments suitably designed for dual physical/mental health needs. The quality, delivery and availability of a suitable care provider sits within the responsibility of the local authority and the CQC. Where concerns on quality or safety are identified, the CQC have a wealth of enforcement powers available and will take swift action to ensure the safety of service users. Under the Care Act 2014 local authorities are responsible for achieving a responsive, diverse and sustainable market of service providers that can provide high quality, personalised care and support, to best meet the needs of people. In addition, the CQC and local authorities also have a responsibility to monitor the quality of care provided and minimise the risk of service interruption or failure. Following assent of the Health and Social Care Act 2022 earlier this year, the CQC will be responsible for inspecting local authorities against their Care Act duties from April 2023. The CQC will review, assess and report on council regulated adult social care functions under Part One of the 2014 Care Act, such as prevention, information and advice, market shaping and support services. I hope this response is helpful. Thank you for bringing these concerns to my attention. Kind regards, MARIA CAULFIELD MP
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