Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0256, written 17 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 | 17 Aug 2022 |
|---|---|
| Reference | 2022-0256 |
| Deceased | Susan Regan |
| Coroner | Christopher Murray |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) · 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Pennine Care NHS Foundation Trust via their solicitors, 1 CORONER I am Christopher Stephen Murray, Assistant Coroner, for the Coroner Area of Greater Manchester South 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 the 5th August 2020, The Coroner opened an Inquest into the death of Susan Mary Regan. The investigation concluded at the end of an inquest on the 27th April 2022. The conclusion of the inquest was a narrative form of conclusion of suicide contributed to by a failure by Mental Health Services to recognise her deteriorating mental health and the increased risk she presented and to take effective steps to reduce the risk. The cause of death was 1a) Hanging 4 CIRCUMSTANCES OF THE DEATH Susan Regan was a 61 year old lady who had no relevant past mental health medical history. She was a long serving, well thought of, member of staff at Marks and Spencer. Her husband died in 2017 and this did understandably affect her but save for some minor characteristic anxiety she had no recorded mental health issues. Following furlough from her role at Marks and Spencer, she began to deteriorate in terms of her mental health and her general wellbeing. She became malnourished and dehydrated combined with increasingly disturbed behaviour consistent with anxiety, arguably displaying potential psychotic tendencies and evidence of self-harm. This resulted in a consultation with the G.P. on 12th June 2020, involvement of The Mental Health Access Team on 5th June 2020, the appointment of The Home Based Treatment Team followed by admission to Stepping Hill Hospital in respect of the poor state of her mental and physical health, on 11th June 2020, followed 1 by an assessment under the Mental Health Act on 14th June 2020 resulting in admission to a Mental Health Ward under section 2 of The Mental Health Act. Following improvement in her condition, the section was rescinded on 23rd June 2020 and Mrs Regan was discharged home with continuing support from The Home Based Treatment Team. There were ongoing symptoms and matters reached a head on 23rd July 2020 when Mrs Regan was reported to be at the end of her drive, screaming. Advice was sought and a visit planned for 24th July 2020 at which Mrs Regan was described as anxious, very agitated and rubbing her hands and face. Throughout a series of assessments over the months Mrs Regan would either deny suicidal ideation or avoiding answering the questions. She was known to not want to be hospitalised but her sons remained concerned that she be kept safe. Crucially, they were not consulted on this point 24th July 2020 contrary to the specific instructions of a Doctor when she was consulted on 24th July 2020. There was a failure to have a discussion with Mrs Regan's sons about their opinions on hospitalisation and the risks of not doing so. There was a further failure to record any reference to hospitalisation in their notes following the visit on the morning of 24th July 2020. Mrs Regan's dosage of diazepam was doubled and there appeared to be some improvement in her level of anxiety. A planned visit took place on the morning of 25th July 2020. Later that afternoon Mrs Regan took her own life by as a ligature, around the neck, in her home address. 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) During the course of the Inquest evidence emerged that the clinical guidance of a Doctor required the Home Treatment Team to speak to Ms Regan's sons to explore whether they feel she needed to be admitted on an inpatient psychiatric unit. Admission to also be considered if Ms Regan would continue to show non- compliance on her medications. Such an enquiry was not undertaken. 2) It was also confirmed in evidence that there was a failure to properly record a plan and properly communicate such a plan with Mrs Regan’s sons. 2 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1. I am concerned that advice from senior clinicians was not followed and appropriate plans not drawn up by the Home Treatment Team. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12th October 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 namely , on behalf of the Family, who may find it useful or of interest. 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 Christopher Stephen Murray HM Assistant Coroner 17.08.22 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.
Corporate Services
Trust Headquarters
225 Old Street
Ashton Under Lyne
Lancashire
OL6 7SF
5th December 2022
Private & Confidential
Mr Christopher Murray
HM Assistant Coroner
Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Mr Murray
I write in response to your Regulation 28 report dated 17th August 2022 and in
respect of the concerns you have highlighted after hearing evidence at the Inquest of
Ms Susan Mary Regan.
Your Matters of Concern have been reviewed and Pennine Care's response is
outlined below.
Matter of Concern 1
During the Inquest evidence emerged that the clinical guidance of a Doctor required
the Home Treatment Team to speak to Ms Regan’s sons to explore whether they
feel she needed to be admitted on an Inpatient psychiatric unit. Admission to also be
considered if Ms Regan would continue to show non-compliance on her medications.
Such an enquiry was not undertaken.
Response - Working Collaboratively with Carers
The Trust continues to support and promote the Triangle of Care, which is a
therapeutic alliance between the service user, staff member and carer to promote
safety, support recovery and sustain wellbeing.
During the Covid 19 Pandemic supportive forums for services to engage such as the
Triangle of Care forum were stepped down as per Government advice as the NHS
entered Alert Level 4. Since the unfortunate death of Ms Regan, there have been
several improvements made to recognise and empower carer involvement.
These improvements include the establishment of a Patient and Carer Involvement
team within the Trust, a Head of Patient and Care Experience and Engagement
appointed to role, a developed pathway for Lived Experience members to participate
in paid roles including for example reviewing Serious Incident investigations and
participating in service redesign.
The Trust has also strived to re-establish supportive forums to review standards of
the Triangle of Care, carer experience, involvement, and improvement. The model
offers a clear pathway for discussion and escalation from care hub to Trust board.
Stockport services re-established the Triangle of Care meetings in June 2021. These
are well attended by both staff from services, carers with lived experience and carer
support groups and offer valuable insight into carers experiences of services and
supporting local improvements within the Stockport mental health services.
A CQC Inspector has recently attended the Stockport Triangle of Care meeting and
described it as a ‘Well chaired meeting and all members were comfortable to
contribute which was good to see’.
To further support individual services to benchmark against the 6 key standards of
Triangle of Care and develop improvements in clinical areas a Stockport Care Hub
Carers Champion meeting has also been established in-between Triangle of Care
meetings for nominated carer champions within services to attend.
The Home Treatment Team (HTT) now have an identified carer champion within the
service (in line with the Triangle of Care standards and NICE guidance NG150), who
can offer contact and information for carers around education and signposting, as
well as supporting the team to raise awareness and offer information for carers.
The Trust continues to provide carer co-produced and co-facilitated carer awareness
training which is well received. On the back of successfully engaging carers
champions within services, the number of facilitators to support carers to deliver this
training is also now starting to expand.
Carer surveys are now in place and intermittently given and sent out to carers to
complete both in paper form and electronically, to allow carers to have a voice,
independently express their experience as a carer supporting a loving within our
services and identify areas for improvement. The feedback is listened to both at a
local and trust wide level to ensure shared learning and consistent improvement
across all services.
Matter of Concern 2
It was also confirmed in evidence that there was a failure to properly record a plan
and properly communicate such a plan with Mrs Regan’s sons.
Response - Documentation
The HTT has also updated and improved printable information leaflets for patients
and carers with information around how to support their loved ones, additional
voluntary and charity services who may be able to help including apps, helplines,
and online support, as well as a clear contact number for the service to speak
directly with the HTT.
The team strive to actively involve loved ones in all aspects of their personal care
and treatment whilst under the HTT, from assessment to decision making to safety
planning, this is embedded within the vision of the team.
It is recognised and understood that families and loved ones are vital to safety
planning and are often critical within someone’s safety plan being identified to keep a
person safe.
The team completes consent to share forms with people using the service to ensure
that all members of the team are aware of the level of input and information sharing
between the patient, loved ones and the service, as supported by NICE Quality
Standard QS189.
The death of Ms Regan and subsequent internal serious incident investigation and
learning has been shared with the HTT. The importance of timely and accurate
documentation within patient case notes including agreed care plans has been
raised within all disciplines within the team.
Ensuring Communication between Team Members
It is also crucial to note that since the death of Ms Regan, the HTT now has a
substantive Consultant Psychiatrist in place. This has brought a greater degree and
consistency for both the team and patients using the service. The Multi-Disciplinary
meetings (MDM’s) have been adjusted to ensure regular attendance of the
consultant. This has allowed a better degree of communication and care planning
with mutually agreed goals and actions.
I trust this response assures you that the Trust has taken your concerns seriously
and has thoroughly reviewed the issues raised.
Yours sincerely
Executive Director of Quality, Nursing & Healthcare Professionals/Deputy CEO
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