Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0266, written 26 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 | 26 Aug 2022 |
|---|---|
| Reference | 2022-0266 |
| Deceased | Christopher Lloyd |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Pennine Care 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 THIS REPORT IS BEING SENT TO: The Rt. Hon. Steve Barclay MP, Secretary of State for Health and Social Care, Department of Health and Social Care, 39 Victoria Street, London, SW1U OEU CORONER I am Chris Morris, Area Coroner for Manchester South. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 1st April 2021, Andrew Bridgman, Assistant Coroner, opened an inquest into the death of Mr Christopher Michael Lloyd, who died at his home on 14th March 2021, aged 32 years. The investigation concluded at the end of the inquest which I heard between 15th – 17th August 2022. In the light of a Post Mortem examination, the inquest determined that Mr Lloyd died as a consequence of hanging. The conclusion of the inquest as to Mr Lloyd’s death was one of Suicide. CIRCUMSTANCES OF THE DEATH Mr Lloyd died at his home having suspended himself by the neck with a ligature. Mr Lloyd had a long history of poor mental health, and considered himself to have Post Traumatic Stress Disorder. He also had a significant history of substance misuse, and at various points throughout his life had been known to use alcohol, cocaine and cannabis in a potentially detrimental manner. Mr Lloyd had also been known to take although these medicines were not prescribed to him. At the time of his death, Mr Lloyd’s key treatment goal was to be abstinent from all substances and to have an assessment of his mental health. 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 MATTER OF CONCERN is as follows. – 1. Whilst Mr Lloyd had some interactions with mental health services, and was under the care of a charity who provides support as a consequence of alcohol and drug addiction, it is a matter of concern that he did not have ready access to a dual-diagnosis service locally. A unified service of this nature, employing appropriate specialists, would have the benefit of being able to assess and treat mental-health conditions existing alongside substance misuse issues in a coherent and holistic manner. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st 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 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to on behalf of Mr Lloyd’s family. I have also sent a copy to Pennine Care NHS Foundation Trust and Greater Manchester Police as other Interested Persons to the case. I have sent a copy of my report to the Tameside Metropolitan Borough Council, Change Grow Live (My Recovery, Tameside) and Greater Manchester Health and Social Care Partnership, 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. Dated: 26th August 2022 Signature: Chris Morris HM Area Coroner, Manchester South.
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.
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 Mr Christopher Morris HM Area Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris, Thank you for your letter of 26 August 2022 about the death of Christopher Michael Lloyd. I am replying as Minister with responsibility for Mental Health at the Department of Health and Social Care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Lloyd’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 several actions have been taken by the Greater Manchester Integrated Care Partnership (ICP) following Mr Lloyd’s death, including the development of a Co- Occurring Conditions team who will deliver system-wide training in recognition of the complexities and contexts of those with co-occurring conditions. This work will involve a range of stakeholders including the local NHS local authorities and the Voluntary, Community and Social Enterprise sector. More locally in Tameside, a Living Well Plus service launched on 1 August 2022 that sits within Mental Health services and will predominately work with people who are high intense users of A&E, a number of whom have co-occurring presentations. This will also help broader understanding of the issues with treatment pathways that affect people in Tameside. The Office for Health Improvement and Disparities (OHID) has previously published Better Care for People with Co-Occurring Mental Health and Alcohol/Drug Use Conditions, a guide for commissioners and services providers informed by clinical evidence and expertise.1 Two principles from that guide, which should be followed routinely, are that people with co- 1https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/625809/Co -occurring_mental_health_and_alcohol_drug_use_conditions.pdf occurring conditions should face ‘no wrong door’, and that managing drug and alcohol use is “everyone’s job” meaning any service the individual interacts with should support them. In addition, clinical evidence informs the clinical guidelines for those with co-occurring mental health and substance misuse, specifically the National Institute for Health and Care Excellence (NICE) guideline Coexisting Severe Mental Illness and Substance Misuse: Community Health and Social Care Services.2 This guidance asks mental health services to ensure that, upon referral of a new patient, they do not exclude people with severe mental illness because of their substance misuse, undertake a comprehensive assessment of the person's mental health and substance misuse needs and, where the patient is accepted by mental health services, take responsibility to ensure the care coordinator works with other services to address the person's social care, housing, physical and mental health needs, as well as their substance misuse problems, and provide any other support they may need. Further to this, the UK guidelines on clinical management of drug misuse and dependence3 and the NHS Community Mental Health Framework for Adults and Older Adults4 state that, for those with co-occurring mental health and substance misuse, drug and alcohol treatment services, working with mental health services, should act to ensure they are simultaneously addressing mental health and substance use symptoms, eliminating exclusions based on a person’s diagnosis and stepping up the intensity of treatment centered around their needs. In response to your recommendation for further, separate provision of specific dual diagnosis treatment services alongside mental health and substance misuse services, it is important to point out such service structures are not backed by evidence and so not recommended in the published guidance. Moreover, the Government published From harm to hope: a 10-year Drug Strategy in- response to Dame Carol Black’s independent review on drugs.5 One of the three priorities of this strategy is to deliver a world-class treatment and recovery system, backed by an additional £780m over three years. Of this, £532 million has been made available to local authorities to increase and improve treatment services to reduce harm and improve recovery rate significantly. This will include better integrating treatment services to ensure people’s mental and physical health needs are met. OHID is also currently working with NHS England and the wider sector to identify ways to improve the integration of services, including better implementation of the existing guidance. Finally, through its Long-Term Plan, the NHS has committed additional funding to improve mental health provision. The Department has also recently held a 12-week call for evidence to inform a new 10-year plan to improve mental health. We are currently considering the responses to this and undertaking wider stakeholder engagement. We will 2 https://www.nice.org.uk/guidance/ng58/ 3https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/673978/cli nical_guidelines_2017.pdf 4 https://www.england.nhs.uk/wp-content/uploads/2019/09/community-mental-health-framework-for-adults- and-older-adults.pdf 5 https://www.gov.uk/government/publications/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and- save-lives publish a full response to the call for evidence along with further detail on next steps in due course. These actions combined will work to ensure that future cases of people with co-occurring mental health and substance misuse receive a world-class treatment system, which can work better in partnership with mental health services to prevent avoidable deaths and improve treatment outcomes for the people affected. I hope this response is helpful and thank you for bringing these concerns to my attention. Kind regards, MARIA CAULFIELD MP
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