Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0245, written 4 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Aug 2022 |
|---|---|
| Reference | 2022-0245 |
| Deceased | Stanislav Mucha |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Royal College of Psychiatrists, 21 Prescot Street, London, E1 8BB
2. Secretary of State for Health, The Rt Hon Steve Barclay MP, 39 Victoria Street London, SW1 H 0EU
CORONER
I am Ms Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North
CORONER'S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013
INVESTIGATION and INQUEST
On the 7th July 2022 I concluded the Inquest into the death of Stanislav Mucha who died on the 3rd February
2021 at Salford Royal Hospital.
The medical cause of death was recorded as :
1a) Polytrauma
The conclusion was a narrative conclusion - Died as a result of catastrophic injuries sustained after he jumped
at the Rock centre in Bury. There was no evidence of his intention and he
from the
had a history of psychosis.
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CIRCUMSTANCES OF DEATH
Stanislav was 17 years old when he died on the 3rd February 2022. In concerns had been raised about his
mental health and he was admitted as an inpatient. He was diagnosed with acute on-set psychosis. He was
discharged from hospital in May 2020 and his care was passed to the Early Intervention team .
Stanislav presented as a high risk to others. He travelled to Slovakia with his family in September 2020 and
he returned in January 2021 . At this time there had been a clear deterioration in his mental health.
There are repeated attempts to engage him and referrals for a mental health act assessment. On the 22nd
January the court heard that a mental health act assessment was attempted at the home address. In
attendance was a Section 12 approved independent psychiatrist, a Consultant Psychiatrist from the treating
trust, the Approved Mental Health Practitioner and a professional who was involved in sourcing a bed for
Stanislav.
All members of this group gave evidence to the court as to what they understood had occurred on this day.
There was a difference in opinion as to whether :-
a) A mental health act assessment had been conducted. The psychiatrists were of the opinion due to the
brevity of time in which Stanislav was observed, merely walking past them into the house, an
assessment was not done. This was at odds with the AMP who believed an assessment had been
conducted.
b) The next steps which were to be taken. Three of the professionals understood an application to the
Magistrates court for a Section 135 warrant to allow entry into the property. This was not the
understanding of the AMP who did not progress this action, having formed the opinion an assessment
had in fact taken place.
The Court heard evidence the Psychiatrists were expecting a further attempt to conduct an assessment later
that day or the next day.
On the 26th January 2021 Stanislav's treating Consultant Psychiatrist became aware of the outcome of the
mental health act assessment. Due to ongoing concerns in relation to Stanislavs mental health a further mental
health act assessment was arranged for the 3rd February 2021 .
Stanislav jumoed
of the 3rd February 2021.
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CORONE~SCONCERNS
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. The Independent Section 12 Consultant Psychiatrist did not make and the court heard does not have
the facilities to make any notes in relation to the assessment.
2. Following the assessment on the 22nd January 2021 there was no documented agreement as to the
outcome of the assessment between all professionals. This would have negated the confusion and
lack of understanding as to what had occurred and the actions required.
3.
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ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe each of you respectively
have the power to take such action.
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YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely Friday 30th
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.
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COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- the family
of Mr Mucha.
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 from. 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.
Date: 4th August 2022 Signed: {J-1-~,
/1
3 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.
Subject: Regulation 28 Stanislav Mucha - Bury Council response (Attachments:) Regulation 28 - Stanislav Mucha.pdf, Mental Health Act Assessment Recording Document 22.08.22.docx :CAUTION: This email originated from outside of the organisation. Do not click links or open attachments unless you recognise the sender and know the content is safe. Dear Ms Kearsley I am responding to the above attached regulation 28 Sec 5 points 1. 2. 3 My sincere apologies at the delay in sending you the actions taken to improve communications and recording when mental health act assessment decisions do not recommend detention under the act as was the case with the late Mr Mucha. Interim Lead AMHP (Approved Mental Health Professional) for Bury Council has written to me with the following steps that have now been implemented as result of the above issuance of the Regulation 28: The coroner had highlighted the lack of documentation from the Section 12 appointed doctor and a no documented agreements with the professionals when carrying out mental health act assessments. 1. To rectify this, I have devised a mental health assessment recording act template (attached for information), which the all Section 12 doctors now complete when they attend a mental health act assessment and when they don't make a medical recommendation. 2. The section 12 doctors must provide their rationale to why they have not made a recommendation and describe any alternative plans following the assessment. 3. Additionally, all AMHPs now complete a social circumstance report when the decision is made not to detain a patient as previously some AMHPs were not completing social circumstance report when a patient was not detained. All social reports outlines the rationale for the decision not to admit a patient and any alternative plans to hospital admissions which was established. I hope this provides a level of assurance that the steps put into place in Bury will ensure the situation with the late Mr Mucha does not arise again in the future. Kind regards Principal Social Worker Adults Bury Council, One Commissioning Organisation, Community Commissioning Division A7
From Maria Caulfield MP
Parliamentary Under Secretary of State for
Mental Health and Women’s Health Strategy
39 Victoria Street
London
SW1H 0EU
020 7210 4850
23rd December 2022
Ms Joanne Kersley
The Coroner’s Office
Newgate House
Newgate
Rochdale
OL16 1AT
Dear Ms Kearsley,
Thank you for your letter of 4 August 2022 about the death of Stanislav Mucha. I am replying
as Minister with responsibility for Mental Health and thank you for the additional time allowed.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Mucha’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 and
the Care Quality Commission. I understand that at the time of the incident there was no shared
electronic record common to all practitioners. Community teams used PARIS (electronic
system) whilst inpatient services used a paper-based system. Pennine Care Foundation Trust
now have a shared electronic system across services, except for Improving Access to
Psychological Services (IAPT) who conform to the National Recording Keeping Requirements.
In addition, The Trust has recommended the uploading of Mental Health Act documentation
into patient records so that outcome and action plans are clear and explicit. This will ensure a
common record accessible to all with clear plans and goals to minimise the risk of confusion.
The Mental Health Act 1983 Code of Practice explicitly places the duty to record the outcome
of an assessment on the Approved Mental Health Professional (AMHP). If the AMHP believed
that an assessment had taken place, this should have been recorded and communicated to
the Section 12 doctors. Relevant sections of the Code of Practice are below:
a. 14:41 … AMHPs who assess patients for possible detention under the Act have
overall responsibility for co-ordinating the process of assessment
b. 14.100 Having decided whether or not to make an application for admission,
AMHPs should inform the patient, giving their reasons. Subject to the normal
considerations of patient confidentiality, AMHPs should also give their decision and
the reasons for it to:
•
•
•
the patient’s nearest relative
the doctors involved in the assessment
the patient’s care co-ordinator (if they have one), and
A5
•
the patient’s GP, if they were not one of the doctors involved in the
assessment.
c. 14.104 Where AMHPs decide not to apply for a patient’s detention they should
record the reasons for their decision
b. 14.107 Arrangements should be made to ensure that information about
assessments and their outcome is passed to professional colleagues where
appropriate
In addition, Section 14.75 of the Code of Practice places a responsibility on Section 12 doctors
to record their decisions if an assessment has taken place. However, the Code of Practice is
not explicit on how these notes should be recorded. We note that there was some dispute
about whether an assessment had taken place.
In cases where there is a dispute, the Code then sets out the steps which should be taken
with regard to the patient:
d. 14.110 Where there is an unresolved dispute about an application for detention, it
is essential that the professionals do not abandon the patient. Instead, they should
explore and agree an alternative plan – if necessary on a temporary basis. Such a
plan should include a risk assessment and identification of the arrangements for
managing the risks. The alternative plan should be recorded in writing, as should
the arrangements for reviewing it. Copies should be made available to all those
who need it (subject to the normal considerations of patient confidentiality).
The Code of Practice does not state the timeframes in which notes of any assessment should
be produced and made available. As you may be aware, work is currently in train to reform
the Mental Health Act and subsequently its Code of Practice. As part of these reforms we will
consider whether the revised Code of Practice should include a specific time period during
which notes of any assessment should be produced. I am therefore very grateful that you have
brought this matter to my attention.
I hope this response is helpful. Thank you again for bringing these concerns to my attention.
MARIA CAULFIELD MP
A6
Ms J Kearsley HM Senior Coroner Greater Manchester North Floors 2 & 3 Newgate House Newgate Rochdale OL16 1AT Dear Ms Kearsley, Re: Stanislav Mucha (Regulation 28: Report to Prevent Future Deaths). On behalf of the Royal College of Psychiatrists, I am most grateful for the opportunity to comment upon this report, apologies for the delay in responding. I would like to extend my deepest sympathies to Stanislav Mucha’s family and loved ones. The Royal College of Psychiatrists (RCPsych) is the professional medical body responsible for supporting psychiatrists. The College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. The College does not work on the care of individuals and I am not able to comment on the specific circumstances surrounding the case of the death of Stanislav Mucha. However, I have considered your findings, and have the following comments to make in relation the two concerns that you raise: Facilities to make notes in relation to an assessment. The College is very clear that it is good practice to document all clinical contacts, and this is a routine expectation of healthcare professionals across a spectrum of practice. While we are happy to use appropriate communication mechanisms to remind our members of this, in this case the Section 12 doctor seems to assert that there was no facility for them to do so. This being the case, it would seem to be an issue that needs to be addressed as an operational issue in the specific area so that there are the opportunities in place for the details of the interaction to be recorded. Outcome of the Assessment Our initial thoughts on this are that the way the system is designed means that there should not be a lack of clarity or ability to come to a clear outcome. Outcomes of MHA assessments are decided by any one of the 3 assessors (1st rec doctor, S12 doctor, AMHP) not recommending compulsory powers and then the AMHP having a final veto on the application. A3 The MHA works by generating outcomes where there may be disagreements between the assessors. That’s a key objective of the system and is an intended safeguard. We would be happy to comment further on this aspect if there is more detail to be provided in relation to this aspect of the Report. Actions to be taken by RCPsych RCPsych will use communication opportunities to: Remind them of the need for consistent and comprehensive recording of all clinical contacts, including those which emerge through the Mental Health Act. Please do not hesitate to contact me if I can be of any further assistance. Yours sincerely, Registrar Royal College of Psychiatrists A4
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