Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0209, written 13 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 | 13 Jul 2022 |
|---|---|
| Reference | 2022-0209 |
| Deceased | Daniel Clements |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire Western |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Organisation named | South West Yorkshire Partnership Teaching 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Rt Hon Steve Barclay MP, Secretary of State for Health and Social Care 2. South West Yorkshire Partnership NHS Foundation Trust 1 CORONER I am Kevin Mcloughlin, Senior Coroner for the Coroner area of West Yorkshire (Eastern) 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 3 August 2021 I commenced an investigation into the death of Daniel Clements, aged 27. The investigation concluded at the end of the Inquest on 13 July 2022. A conclusion of suicide was recorded based upon a cause of death of 1 a Multiple Injuries. 4 CIRCUMSTANCES OF THE DEATH Daniel Clements aged 27 was a troubled young man. On Monday 19 July 2021 he was taken to hospital by the police and underwent a psychiatric assessment that afternoon. He was deemed not to be suffering from a mental illness and was discharged to his GP . At 20:45 hours the same day he ran into the path of a fast-moving train and sustained fatal injuries. 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) How can a person displaying suicidal ideation be kept safe, if deemed not to be mentally ill? (2) Daniel Clements was a troubled young man aged 27. He had a low IQ, little education and was not fully compliant with his prescribed Risperidone medication (used to treat psychotic illness). He had always been dependent upon his mother, but when she was admitted to a care home in February 2021 (during the Coronavirus pandemic) he became homeless and adrift in society. In short, he was a vulnerable young man. 1 (3) In the fortnight before his death Mr Clements had the following interactions with healthcare professionals: a) On 6 July 2021 he attended an A&E department and reported a deterioration in his mental health with symptoms of anxiety, inability to sleep, drug debts and homelessness, which were deemed attributable to his social situation rather than mental illness. He was referred back to his GP and advised to contact the police if he became concerned about his own safety. He was considered at that time to have the mental capacity to make choices affecting his social situation. b) On 8 July 2021 he sought help from his GP and was referred to the Crisis Team (the Intensive Home-Based Treatment Team). c) On 12 July 2021 his brother contacted the Single Point of Access to voice concerns about his mental state as Mr Clements was phoning him through the night and coming to his home. A representative from the Single Point of Access discussed with the brother options which included seeking an injunction against Mr Clements. He had sought a replacement prescription from his GP but had allegedly been refused an early issue of his medication. d) On 19 July 2021 Mr Clements was brought by the police to the A&E Department at Pinderfields Hospital who referred him to the Psychiatrist Liaison Team. He was assessed by a registered mental health nurse and a Psychiatric Liaison Practitioner. They concluded he did not present with any symptoms indicative of an acute mental illness. He said in response to a direct question that he was "always suicidal". Mr Clements was advised to collect his medication from the pharmacy, to work with housing, pay some of his drug debts and was given a leaflet outlining the Psychiatric Liaison Team Service. (4) Mr Clements was passed between agencies without any lasting benefit. This tragic situation illustrates the void in relation to those with suicidal feelings without any overt psychiatric illness. (5) The Secretary of State for Health and Social Care is asked to consider whether an extension to the Section 136 Mental Health Act 1983 power is required in order that a person such as Mr Clements could be detained for a few days in order to help him through a period of crisis. In this period a multi-disciplinary meeting involving the family, social worker, GP and psychiatric specialist might devise a plan to combat the social problems which otherwise devour the time of healthcare professionals without any conspicuous gain 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and the Trust 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 Monday 5 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: , Sister 1. 2. 3. 4. British Transport Police, FAO: 5. , Brother White Rose Surgery , South West Yorkshire Partnership NHS Foundation Trust 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 Kevin Mcloughlin Senior Coroner West Yorkshire (Eastern) 13th July 2022 3
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 Parliamentary Under Secretary of State for Mental Health and Women’s Health Strategy 39 Victoria Street London SW1H 0EU 3 February 2023 Kevin McLoughlin Senior Coroner West Yorkshire (Eastern) Coroner’s Office and Court 71 Northgate Wakefield WF1 3BS Dear Mr McLoughlin, Thank you for your letter of 13 July 2022, to the Secretary of State for Health and Social Care, about the death of Mr Daniel Clements. I am replying as Minister with responsibility for Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Clements’s death, and I offer my sincere condolences to his 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 as well as the relevant regulator in this instance, the Care Quality Commission (CQC). I am further advised that South West Yorkshire Partnership NHS Foundation Trust have provided a detailed response to your report, which has been shared with me. The Mental Health Act relates only to those who are suffering from mental disorder. It does not cover people with suicidal ideation who are deemed not to be acutely mentally unwell at the point of assessment. An individual in crisis can be detained for assessment for up to 28 days under Section 2 of the Mental Health Act, if clinicians assess that the patient may have a mental health condition of a nature and degree that makes detention appropriate and they ought to be detained for their health and safety. During this time, practitioners can assess the patient’s condition and address the underlying social circumstances that may be contributing to their mental health condition. The forthcoming reforms to the Mental Health Act (set out in the draft Mental Health Bill published in June 2022) are intended to make care more person-centred, providing more advocacy support and improving care planning. These reforms will ensure that the purpose of detention is to help patients recover and be discharged into the community. We have closely considered your recommendation to extend section 136 of the Mental Health Act. Section 136 is primarily a conveyancing power to bring someone to a place of safety and is not designed to allow for care planning. We recognise the desire to ensure that vulnerable people in crisis get the support they need. However, rather than expanding the scope of legislation we believe that the concerns you identify would be better addressed through expanding community services. Amending the Mental Health Act to permit the detention of people without acute mental health conditions would likely result in many more detentions. This could also risk discouraging people seeking support if they were suicidal for fear of detention. The fear of detention is already a barrier to seeking help, especially in BAME communities. Where individuals are not experiencing mental illness of a severity that makes detention under the Mental Health Act appropriate, their needs should be met in the community where partnership between Local Authorities, NHS organisations and Voluntary sector organisations is so critical. Local Authorities hold a range of duties under the Care Act 2014 to promote individual wellbeing, provide information and advice, safeguard adults from abuse and neglect as well as promote the integration of health and care services for those in need of care and support. The expansion of crisis services in the NHS Long Term Plan, backed up by £150m of additional capital funding for crisis centres, will support this aim alongside system partners. For example, one key intention of the investment in crisis cafes and crisis houses is that people should be able to receive crisis support even if they do not reach the threshold of the Mental Health Act. In addition, expanded crisis services will include signposting to other services and joined-up support with the voluntary and community sector, helping people address the factors contributing to their crisis. Further, in September 2022, the National Institute for Health and Care Excellence (NICE) published new guidance on the assessment, management and preventing recurrence of self-harm.1 To support services to adhere to this guidance, and to enable a definitive change in clinical practice and culture, the Department and NHS England will work with NICE and experts in suicide and self-harm prevention to further develop evidence-based best practice in safety planning and the management of needs and risks. This work will be co-produced by experts with experience in the field and in line with evidenced based practice. In addition, the NHS Long Term Plan will see an additional £2.3bn funding invested in mental health services by 2023/24 and aims to ensure people can always access care in a timely way and in the most appropriate setting for their needs, regardless of where they present in the system. This aim is underpinned by significant expansion and investment in adult community crisis and acute mental health services. NHS England are investing almost £1bn extra funding into the transformation of new models of community mental health services in all areas of the country, which includes a specific focus on integration between primary 1 https://www.nice.org.uk/guidance/ng225 and secondary care. Additionally, there is universal access, via NHS 111, to 24/7 community-based crisis care, including a range of alternative services to hospital admission, such as crisis houses and safe havens. With regard to increased joined-up working between and within local organisations, the Health and Care Act 2022 is a key part of the Government’s agenda to increase collaboration between the NHS and local authorities to improve health and wellbeing outcomes. The Act has brought about the formation of Integrated Care Systems, which bring together a wide range of partners to deliver more joined-up, personalised and preventative care for population and communities through more joined-up decision making across NHS Bodies, local authorities and other partners. Furthermore, in February, the Government published its integration white paper Joining Up Care for People, Places and Populations.2 The paper recognised the importance of clarity of accountability for delivering integrated care at the local, or ‘place’ level, and it set out opportunities for how this could be achieved. The Government is continuing with plans to further develop the opportunities set out in the white paper, to ensure all places have clear governance arrangements and accountability structures that deliver strong, effective leadership. I hope this response is helpful and I thank you for bringing these concerns to my attention. Kind regards, MARIA CAULFIELD MP 2 https://www.gov.uk/government/publications/health-and-social-care-integration-joining-up-care-for- people-places-and-populations
26 September 2022 Mr McLoughlin HM Senior Coroner, West Yorkshire (Eastern) Coroner’s Office and Court 71 Northgate Wakefield WF1 3BS Dear Sir, Regulation 28 Response - Daniel Clements Trust Headquarters Fieldhead Hospital Ouchthorpe Lane Wakefield WF1 3SP We write in response to the Regulation 28 report following the inquest touching the death of Mr Daniel Clements. We would like to offer the family of Mr Daniel Clements our sincere condolences for this loss. We hope the information supplied in this response provides assurance that the concerns raised are important to the Trust and shows how we, as a secondary mental health care provider, work with partner organisations to ensure the safety of a person who does not present with a mental illness, but experiences suicidal ideation (for example through social circumstances). The Trust recognises that many factors contribute to the risk of a person taking their own life. Suicide is highly complex and each person’s experiences of suicidal thoughts and actions are individual. Skilled assessment, listening to how and why the person’s thoughts are looking towards death and supporting that person to turn towards life and keep themselves safe is crucial in developing a clear plan to reduce risk. Where an intervention capable of reducing the risk of suicide can be provided by the Trust, we aim to achieve excellence in this regard, for example in the treatment of mood disorders. However, where resolution of a problem lies beyond the scope of services provided by the Trust, we will endeavour to ensure that the person and their carers are offered support in accessing an appropriate service, often involving partner organisations. The Trust views suicide prevention as a role that extends outside of our own organisation, and would extend to primary care, other mental health and social care providers, emergency services, addiction services, housing, independent and voluntary sectors among others. The Trust works closely and in partnership as a part of the regional suicide prevention public health aims and ambitions across West and South Yorkshire. Following an assessment of a person by secondary mental health services, and where no mental illness is identified, practitioners would focus on the problem areas highlighted in the assessment and consider partner organisations that can best assist with their problems. Such organisations often provide consent based or self-referral services, as the person’s active engagement with the service is required. Practitioners will, on a case-by-case basis, consider with the person whether sign posting, referral or self- referral is the most appropriate option. For example, where debt is causing stress and suicidal thoughts, information regarding the Citizens Advice Bureau would be given. Where drug misuse is the main problem, information on Inspiring Recovery, a local drug and alcohol service, would be supplied. There would also be a discussion regarding the alternative organisations that they can access which provide support for people with suicidal thoughts. These include: • The Mental Health Support line. This is a telephone service which supports people who are: o At risk of developing mental health problems o Diagnosed with common mental health problems o Want help accessing mental health support o Experiencing mental health distress o Seeking information, advice and support • ‘Safe Space’ is open to anyone in a crisis. This is a partnership between Touchstone, Spectrum People and Gasped. The Wakefield Safe Space is funded by the Wakefield District Health and Care Partnership (previously known as Wakefield CCG), part of West Yorkshire Integrated Care Board, and is open Monday, Tuesday, Thursday, Friday, Saturday and Sunday from 6pm-12am. Their support can be face to face, telephone and Zoom. • The Samaritans is a 24hr/7 day a week service for anyone experiencing suicidal thoughts, or anyone concerned about friends/family. If the assessing practitioner identified any adult social care needs during their assessment, they can make a referral to Social Care Direct (SCD – Local Authority service provision) or provide the person with the details to enable the service user to make a self-referral, such as if a practitioner had any concerns relating to safeguarding or homelessness matters. Although Social Care Direct is a 24 hour and 7 day a week service, some of the advice services (i.e. homelessness services) may not be available during all hours. Therefore, advice on ‘next steps’ may differ depending on the day and time of the discussion. Where a person’s social circumstances are such that it is considered by the practitioner that talking therapies may help the person better understand their experiences and their impact, a referral or self- referral to Improving Access to Psychological Therapies (IAPT) may be appropriate. The Trust’s services meet with partner organisations referred to above on a frequent basis, the purpose of which is to resolve service interface issues, ensure smooth care pathways and the updating of the system to reflect any service changes. In addition to these meetings, the Trust will propose a meeting with its social care partner, Wakefield Local Authority, to raise with them the contents of your report. As per the above, the Trust has and continues to work closely with its partner organisations and provides appropriate information or referral opportunities, to ensure a person is able to access social support services (as per the commissioning or service arrangements). In response to your concern relating to the use of Section 136 of the Mental Health Act 1983, the Trust does not intend to comment specifically on the legislation but would like to comment on our current provision. Section 136 is the police provision to detain a person they consider may be suffering from a mental disorder and is in immediate need of care or control for the protection of themselves or others. The Trust is commissioned to operate a ‘Health-based Place of Safety’ within Wakefield. The MHA Code of Practice 2015 states that the preferred location for a place of safety is a Health-based Place of Safety where mental health services are provided, and a Police station should only be used as a Place of Safety in exceptional circumstances. The Trust’s Wakefield Health-based Place of Safety provides for one person at a time to be conveyed there by the police for an assessment of the person’s mental health in the form of a Mental Health Act assessment. The current Section 136 provision allows for a person to be assessed within a maximum of 36 hours. A Health-based Place of Safety does not provide any facilities to maintain a person for any other purpose or beyond the duration of the S136 detention. We are grateful for the opportunity to share with you the Trust’s approach to the concerns raised within the Regulation 28 report. We hope it assures you and the family of Mr Clements that Trust services make every effort to ensure a person can access appropriate commissioned services to address their social needs, needs that cannot otherwise be addressed by a secondary mental health care provider. Yours sincerely, Chief Nurse / Director of Quality and Professions
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