Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0201, written 29 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 | 29 Jun 2022 |
|---|---|
| Reference | 2022-0201 |
| Deceased | Paul Meadows |
| Coroner | Peter Taheri |
| Coroner area | Suffolk |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths |
| Organisation named | Norfolk and Suffolk 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (Chief Officer) Ipswich & East Suffolk Clinical Commissioning Group The Right Honourable Sajid Javid MP Secretary of State for Health and Social Care 1 CORONER I am Peter Taheri, Assistant Coroner, for the coroner area of Suffolk. 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 11th August 2021 an investigation was commenced into the death of Paul Alexander Meadows. The investigation concluded at the end of the inquest on 10th June 2022. The narrative conclusion of the inquest was that: Paul Alexander Meadows died on 4th August 2021 at 73 Richmond Road, Ipswich, Suffolk. He took a Codeine overdose that caused his death amid a background of both a number of physical health difficulties that he did not feel were remedied by medication and an escalation in mental ill health, to the extent that he was experiencing a mental health crisis. There is not sufficient evidence to conclude that he took this overdose of prescription medication on this occasion intending to take his own life. Paul had sought assistance from agencies including the First Response Service, speaking with the latter on numerous occasions. On at least the last occasion he spoke with the First Response Service, the 3rd August 2021, although he did not communicate an immediate intent to end his life, the mental health crisis that he was experiencing was not recognised and there was no onward referral. The medical cause of death was confirmed as: 1(a) Overdose of Codeine 4 CIRCUMSTANCES OF THE DEATH Paul Alexander Meadows unfortunately suffered with numerous medical problems and, in the last months of his life, his mental health deteriorated. On 4th August 2021, after becoming concerned about him due to telephone conversations with him the night before, family members visited his home address to bring round some of his favourite food, to check up on him, and to see if they could help. They found the back gate, unusually, open, the kitchen door wide open, and Paul sadly had already passed away. There were no suspicious circumstances, no evidence of anyone else inside the premises, and multiple empty packets of prescription medication were found. Paul’s death was caused by him having taken an overdose of Codeine. The inquest heard evidence that, between July 2020 and February 2021, Paul had made 15 calls to the First Response Service. While there were no calls between February and July 2021, he made further calls to the First Response Service on 15th July, 16th July, 23rd July, and 3rd August 2021. In these calls, he described both physical health and mental health difficulties. In the later calls, while he did not state any immediate intent to take his own life, and denied any plan or intent to do so, he did make remarks to the effect of being fed up with the pain and not wanting to be here any more. In the 3rd August call, he did describe himself as ‘suicidal’, wanting to die, not coping with life, thinking his head had gone too far, and as thinking he had given up. He described himself as scared that that he might try and take his own life. He also indicated that he had been thinking about self-harming by taking handfuls of pills. While it is fair to note that those are remarks selected from a 40 minute telephone conversation, nevertheless things were said that could have raised a red flag as to suicidality and being in crisis, and which potentially could have prompted consideration of a more urgent intervention. At inquest, the First Response Service acknowledged certain key points: - Even on the 16th July 2021 call, Paul was requesting more immediate help. His saying that no-one was taking him seriously and requesting more immediate help should have raised the level of concern and perceived risk. - The safety plan relied heavily on Paul’s motivation, which was precisely what Paul was saying was absent – and that this absence was something that was worrying him. This issue with the safety plan itself raised the level of risk. - There was a clear escalation in terms of a deterioration in Paul’s mental health. He appeared to be in crisis but this appeared to go unrecognised. The advice given and lack of onward referral appeared to be an inadequate response. I found as a fact that, on the balance of probabilities, Paul was in mental health crisis on at least 3rd August 2021 and that this was not recognised by the First Response Service practitioner. I found that the omissions to recognise that Paul was in mental health crisis on 3rd August 2021 and to make a referral onward for crisis or other urgent or emergency intervention did more than minimally, trivially or negligibly contribute to Paul taking the overdose the following day, even though I could not safely conclude what Paul’s intentions were in taking that overdose. 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. – The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation. It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess. The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls. The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls. The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation. Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response Service practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future. The evidence was also that this is not just a concern in one county, but one that is experienced nationally. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you and / or your organisations 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 24th 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 have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - Paul’s family - Norfolk & Suffolk NHS Foundation Trust I am 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 29th June 2022 Peter Taheri
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.
From Maria Caulfield MP
Parliamentary Under Secretary of State
Department of Health and Social Care
39 Victoria Street
London
SW1H 0EU
5th December 2022
Mr Peter Taheri
Assistant Coroner
Coroner Area of Suffolk
Beacon House
Whitehouse Road
Ipswich, Suffolk
IP1 5PB
Dear Mr Taheri,
Thank you for your letter of 29 June 2022 about the death of Paul Alexander Meadows. I am
replying as Minister with responsibility for Mental Health.
Firstly, I would like to say how deeply saddened I was to read of the circumstances of Mr
Meadows’s death. I can appreciate how distressing his death must be for his family and those
who knew and loved him and I offer my heartfelt condolences. It is of course vital that we take
learnings where they are identified to improve NHS care 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).
There are, sadly, wider patient safety issues in the Norfolk and Suffolk NHS Foundation Trust
which the CQC and NHS England are currently working with the Trust to address. The CQC
is carrying out the enforcement process of a Section 29A Warning Notice and have already
scheduled a follow up inspection, which will be unannounced to the Trust. The CQC’s
engagement and visits to the Trust will continue, with further visits planned for the near future.
The Trust is also in NHS England’s Recovery Support Programme, which provides help to the
most challenged Trusts by ensuring there is greater focus and support on systems, as well as
organisations. The Trust has appointed a new Improvement Director and has produced an
improvement action plan, as required.
My predecessor, Gillian Keegan, also met with families, as well as local MPs, the CQC and
NHS England to ensure that their views are heard in shaping what happens next to support
the Trust to improve services. I will continue this engagement going forwards.
Furthermore, we are committed to supporting everyone’s mental wellbeing and we want to
ensure services are there for anyone who experiences a mental health crisis or has suicidal
thoughts. That is why we are investing at least £2.3 billion of additional funding a year by
2023/24 to expand and transform mental health services in England so that two million more
people will be able to access mental health support.
Additionally, in 2021/22 we provided £500 million to accelerate our expansion plans. Of this,
£110 million was used to expand adult mental health services, including investment in crisis
services and maintaining the delivery of the 24/7 urgent mental health helplines stood up
during in the pandemic.
Over the next 3 years, we are investing £150 million of capital funding into schemes which
address pressures on the local urgent and emergency mental health care pathway. This
includes £7 million to roll out dedicated mental health ambulances from 2023/24 onwards with
up to 100 vehicles across the country by the end of 2024/25.
With regards to differences in funding available to Norfolk and to Suffolk, NHS England is
responsible for determining allocations of financial resources to Integrated Care Boards from
April 2022. The allocations process uses a statistical formula to make geographic distribution
fair and objective, so that it more clearly reflects local healthcare need and helps to reduce
health inequalities. Local commissioners are responsible for decisions about the provision of
services in their area and ensuring that they meet the needs of the local population.
Turning to your matter of concern regarding staff vacancies, we are 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 Health’ and ‘Stepping Forward
to 2020/2021: The mental health workforce plan for England’, we have expanded and
diversified the types of roles that are available.
The latest data shows that, as of June 2022, there are 133,573 full-time equivalent (FTE)
people in the mental health workforce nationally. This includes only those people who work
directly on mental health, across NHS trusts, NHS foundation trusts. and Integrated Care
Boards. This is an increase of over 6,900 more (5.4% increase) FTE staff in the mental health
workforce compared to June 2021.
The NHS Mental Health Implementation Plan 2019/20–2023/24 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. We invested £111 million in 2021/22 to grow the
mental health workforce to deliver these ambitious commitments. Further, Health Education
England and NHS England have been working with Integrated Care Systems (ICSs) to confirm
plans to 2024. The aim is for every ICS to look at everything they can do to meet the
Implementation Plan ambition, including through innovative service models, increasing supply,
and improving retention and recruitment.
Finally, it is unacceptable that Mr Meadows’s 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.
Kind regards,
MARIA CAULFIELD
Suffolk and North East Essex Integrated Care Board Medical Director First Floor Endeavour House 8 Russell Road Ipswich IP1 2BX Telephone: 2 7 JUL 2022 Mr Peter Taheri Assistant Coroner The Coroners Court and Offices Beacon House Whitehouse Road Ipswich IP1 5PB 21st July 2022 Ref: Paul Alexander Meadows Dear Mr Taheri Further to your report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, thank you for sending your concerns for the attention of the Ipswich & East Suffolk Clinical Commissioning Group (now Suffolk and North East Essex Integrated Care Board). These concerns were: "The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in othe~ cases as well as Paul's case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation. It was accepted that, in Summer 2021, due to resource pressure - specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess. Cont./ ... , Chief Executive I , Chair -2- The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies, it would be unfair to say that staff do not still feel pressured at times on calls. The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls. The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation. Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response Service practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future. The evidence was also that this is not just a concern in one county, but one that is experienced nationally." The response to those concerns is as follows. • Suffolk established the First Response Servi.Ce (FRS) mental health telephone line in March 2020 to deliver the aim of the National Health Service England (NHSE) long term plan of 100% coverage of 24/7 age-appropriate crisis-care accessible via NHSE 111. • After consultation with service users and because of the situation nationally with NHSE it was decided to establish the First Response Service as a standalone number. • The initial plan was to have a crisis only telephone number but due to the expected concern caused by Covid, Suffolk were asked by NHSE to adapt the crisis line to be a service that would respond to all mental health enquiries whether they were crisis or not. • This request put additional pressure on the service as practitioners were not only responding to crisis calls but also managing general mental health enquiries from the wider public. • Suffolk has invested £1.3m in the First Response Service and call volumes were considerably higher than planned from the inception of the service. Demand and capacity work was completed as part of the business case underpinning the First Response Service. • Suffolk adequately funded the service from the outset but were not able to financially respond to the sudden increase caused by the request to make the service accessible to anyone with a mental health query. The Suffolk First Response Service was further advanced than the Norfolk equivalent service when the FRS went live in March 2020 and initially supported Norfolk calls too whilst the Norfolk service offer was further developed. • There have been challenges recruiting to the First Response Service team and this is representative of the wider issue with attracting staff to work in Norfolk and Suffolk Foundation Trust (NSFT). NSFT have worked extensively to attract staff across their workforce but are careful to employ people who can add quality to the service. Cont./ ... -3- • Suffolk and North East Essex Integrated Care System (ICS) and NSFT agreed to repurpose the FRS and transition to NHS111 option 2. This would refocus the service to revert to the 'Crisis' Response service that was initially planned. This change in April 2022, has seen a reduction in calls and abandonment rate and seen an improvement in call response times. has also helped the team to spend more time with individuals who are accessing the service. • The amount of funding does not have a direct impact on how NSFT can successfully recruit to vacancies. The ICS has provided additional funding to create additional support from voluntary, community and social enterprise partner(s) to provide targeted help to individuals who access the First Response Service frequently. These approaches have helped to increase capacity for our crisis response teams to support more individual callers. It has also allowed the FRS to have a more focused community approach to reduce crisis situations. It • The ICS will continue to work with NSFT to reduce the number of vacancies in the team and continue to improve the offer for people who are experiencing a mental health crisis in Suffolk. The ICS is committed to working closely with HM Coroner and others to ensure that the local health and care system learns from all deaths, to prevent avoidable harm to our patients. I trust the response provided here adequately responds to your concerns, and I remain available for further assistance should it be required. Yours sincerely Medical Director and CIO I Cc: , CEO SNEE ICB
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