Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0207, written 5 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 | 5 Jul 2022 |
|---|---|
| Reference | 2022-0207 |
| Deceased | Anthony McLellan |
| Coroner | Joan Broadbridge |
| Coroner area | North Yorkshire and York |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Tees, Esk and Wear Valleys 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Humber & N. Yorkshire Health & Care Partnership 2 NHS England and NHS Improvement 1 CORONER I am John BROADBRIDGE, Assistant Coroner for the coroner area of North Yorkshire and York 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 13 July 2021 I commenced an investigation into the death of Antony Christopher MCLELLAN aged 54 (“Mr McLellan”). The investigation concluded at the end of the inquest commenced part heard 1st February and completed 01 July 2022. The conclusion of the inquest was that Mr McLellan died because of suicide. 4 CIRCUMSTANCES OF THE DEATH On 9 July 2021 the deceased was found unresponsive within the garage at his home at . His death was recognised there at 14.19 hours that same hanging by a ligature afternoon, later indicated as from the effects of that hanging. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) 1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”) 2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically. 3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff a) considered the higher prevalence of suicide for individuals with a diagnosis of autism and b) that OFFICIAL - SENSITIVE Regulation 28 – After Inquest Document Template Updated 30/07/2021 Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism. 4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however. 5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire. 6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker ie have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic. 7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life. The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locality but also nationally. Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder. 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 30 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 I have also sent it to the CEO Tees Esk and Wear Valleys NHS Foundation Trust OFFICIAL - SENSITIVE Regulation 28 – After Inquest Document Template Updated 30/07/2021 who may find it useful or of interest. 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 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 by the Chief Coroner. 9 Dated: 05/07/2022 John BROADBRIDGE Assistant Coroner for North Yorkshire and York OFFICIAL - SENSITIVE Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Mr John Broadbridge Assistant Coroner North Yorkshire and York Coroner’s Court The Old Courthouse 3 Racecourse Lane Northallerton North Yorkshire DL7 8QZ National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 17 April 2023 Dear Mr Broadbridge Re: Regulation 28 Report to Prevent Future Deaths – Antony Christopher McLellan who died on 09 July 2021 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 05 July 2022 concerning the death of Antony Christopher McLellan on 09 July 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr McLellan’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Mr McLellan’s care have been listened to and reflected upon. I would like to apologise for the delay in responding to your Report. This was unfortunately due to an administrative oversight during a particularly pressurised time for the NHS, and I would like to offer my sincere apologies to Mr McLellan’s friends and family for this as well as assurances that we have reviewed our processes to prevent it from taking place again. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them. Following the inquest, you raised concerns in your Report regarding the fact that the assessment and formulation of risks and safety summary did not fully explore the impact of Mr McLellan’s autism, including your concern of a higher level of prevalence of suicide in individuals with an autistic marker both locally and nationally. You considered that urgent solutions were required to prevent further deaths of autistic individuals, especially those with a mental health disorder, by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves. As of 1 July 2022, all health and social care providers registered with the Care Quality Commission (CQC) must ensure that their staff receive training on learning disabilities and autism appropriate to their role. The training aims to ensure the health and care workforce have the right skills and knowledge to provide safe, compassionate and informed care to autistic people with a learning disability. The training comes in two tiers: • Tier 1 for staff who need a general awareness of the support autistic people or people with a learning disability may need; • Tier 2 is a one-day face-to-face training session for people who many need to provider care and support for autistic people or people with a learning disability or autistic people co-delivered by a trainer and a person with a learning disability and an autistic person. An eLearning package is the first part of both Tier 1 and Tier 2 and is available through Health Education England (HEE). HEE are building the capacity and capability within ICBs to create a sustainable model. Please see link to FAQs – The Oliver McGowan Mandatory Training on Learning Disability and Autism | Health Education England (hee.nhs.uk)- and e-learning is here: The Oliver McGowan Mandatory Training on Learning Disability and Autism – e learning for healthcare (e-lfh.org.uk) Your Report highlights the importance of ensuring that there is high quality care tailored to individual needs when mental health services are accessed by autistic individuals. In particular, care should be reasonably adjusted and delivered by multidisciplinary staff, who may be working across inpatient, outpatient and community mental health services, and who have knowledge and awareness of autism. Staff working in acute settings, including psychiatric liaison, the designated place of safety (136 suite), home treatment teams and the crisis line, may require additional specialist training around assessment of mental health and emotional wellbeing in autistic individuals. Linking in with the autism service is key for the mental health services. In January 2023, NHS England published a new policy with the aim of preventing unnecessary hospital admission for people with a learning disability and autistic people. This includes new guidance on the implementation of dynamic support registers and updates to the Care (Education) and treatment reviews that will help support good practice across mental health inpatient and community services for autistic here: found policy https://www.england.nhs.uk/publication/dynamic-support-register-and-care- education-and-treatment-review-policy-and-guide/#heading-1. individuals. The can be The NHS Long Term Plan, which is a plan for the future of the NHS, also includes ambitious investment to expand and transform community mental health services for adults and older adults with severe mental illness. From April 2021, all areas are receiving significant additional, ring-fenced funding on a fair-share basis to develop fully integrated primary and community mental health services, that enable people with severe mental illness to have greater choice and control over their care and support them to live well in their communities. By 2023/24, this investment will amount to almost £1billion extra per year for adults and older adults with severe mental illness. Severe mental illness in this context is defined as ‘a range of needs and diagnoses, including psychosis, bipolar disorder, personality disorder, eating disorders, severe depression, and mental health rehabilitation needs – some of which may be co- existing with other impairment, neurodevelopmental conditions or substance use’. The Long Term Plan also includes a commitment to ensuring that the whole of the NHS works to improve its such as conditions cognitive frailty, understanding of the needs of people with learning disabilities and autistic people, to include increased investment in intensive and community support. The Humber and North Yorkshire Integrated Care Board (ICB) is the Commissioner that has adopted the contracts which were held by NHS North Yorkshire Clinical Commissioning Group (CCG) and have shared their response with me. The CCG (and now ICB) commission Tees, Esk, Wear Valley NHS Trust (TEWV) to provide the Mental Health provision to the residents of North Yorkshire. This would be the case whatever the Mental Health condition is and whether that is suspected, being assessed or diagnosed. The contract requires this provision of service. In addition to this where an individual with mental health conditions also has a diagnosis of autism, the contractual expectation would be that TEWV would make reasonable adjustments to their service to ensure that it is delivered to meet the needs of those individuals with autism and a mental health condition. I would also like to provide further assurances on the national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mr McLellan, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director
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