Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0275, written 5 Sep 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 Sep 2022 |
|---|---|
| Reference | 2022-0275 |
| Deceased | James Tice |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | Suicide (from 2015) · Mental Health related deaths · Community health care and emergency services 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive of NHS Greater Manchester Integrated Care 1 CORONER I am Catherine McKenna, Area Coroner for the Coroner area of Manchester North 2 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 3 INVESTIGATION and INQUEST On 4 May 2022 an investigation into the death of James Alan Tice otherwise known as Alan Tice was commenced. The investigation concluded at the end of the inquest on 31 August 2022, I recorded a conclusion of Suicide. The medical cause of death was recorded as 1a) Hypovolemic shock 1b) bleeding from deep cuts 4 CIRCUMSTANCES OF DEATH Mr Tice was 75 years of age when he took his own life at his home address. He had a diagnosis of recurrent depressive disorder with anxiety features and had suffered with this condition for most of his adult life. He had numerous informal admissions to psychiatric hospitals and most recently was discharged from Birch Hill Hospital in Rochdale in February 2022 following an 8 month admission. Following his discharge from hospital, Mr Tice remained under the care of the Home Intensive Treatment Service and the Consultant Psychiatrist. By 26 March 2022, it became apparent that he was experiencing a further relapse in his condition. A request for a hospital bed on an informal admission basis was made on 6 April 2022. The first bed that became available for an older adult was on 28 April 2022 which was the day that Mr Tice took his own life. In addition to the lack of an available bed, the evidence was that Mr Tice required psychotherapy of a type that was over and above the service provided by mental health practitioners offering psychological support on the ward and in the community. The evidence was that a vacancy for the post of in-patient psychologist at Birch Hill Hospital has remained unfilled for a number of months and that a psychotherapy service of the nature required by Mr Tice is not available in the community. 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 ii is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- (1) Availability of beds for patients requiring an informal admission to an older adults mental health ward in the area covered by Pennine Care NHS Foundation Trust (2) Availability of psychotherapy services for older adults in the community whose needs exceed the service available through Thinking Ahead. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 1 November 2022 I, the Area 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:- • • Pennine Care 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 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: 5 September 2022 Signed:
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.
Date: 31 October 2022 Ms A Mutch HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Re: Regulation 28 Report to Prevent Future Deaths – James Alan Tice 09/10/21 Thank you for your Regulation 28 Report dated 06/09/22 concerning the sad death of James Alan Tice on 28/04/22. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Mr Tice family for their loss. Thank you for highlighting your concerns during Mr Tice’ Inquest which concluded on 31 August 2022. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it is also very important to ensure we make the necessary improvements to the quality and safety of future services. The inquest concluded that Alan’s death was a result of 1a) Hypovolemic Shock; 1b) bleeding from deep cuts to both wrists. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken. I hope the response below demonstrates to you and Mr Tice’ family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system. This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning from this case. 1) Availability of beds for patients requiring an informal admission to an older adults mental health ward in the area covered by Pennine Care NHS Foundation Trust. Mr Tice was under the Home Intensive Treatment Services (HITS) following his discharge from Beech ward on 7 February 2022. He was referred to the HITS team for short term intensive follow up prior to be handed back to the Older Peoples Community Mental Health Team. Whilst open to the HITS team he started to relapse, therefore they remained involved for a prolonged period. On the 6 April 2022, it was agreed that he required a further planned inpatient admission to review his treatment in a safe environment and a bed request was made. The delay in sourcing a bed was escalated daily through the Bed Flow Priority Meeting and as there are no privately commissioned beds available within the North of the country for older people’s psychiatry, a bed needed to be identified within Pennine Care NHS FT (PCFT). It was also recognised that both Mr Tice and his wife wanted him to be admitted back to Beech ward. A bed did not come available until three weeks later, the 28 April 2022. On the 28 April 2022 a bed was identified in Stockport. This was on the day of Mr Tice’s death. It is not clear if Mr Tice would have accepted admission to Stockport as this is an out of area bed. 2) Availability of psychotherapy services for older adults in the community whose needs exceed the services available through Thinking Ahead. It was recognised by services that Mr Tice benefitted from a psychological approach to his care. Whilst one staff member was able to offer this approach and was allocated to see Mr Tice regularly when on duty, there was no formal psychologist support. It was recognised by the Organisation intervention from a psychologist would have been of benefit. There is no psychologist support in older people’s services in Heywood, Middleton and Rochdale. It is also recognised that there is an issue in the recruitment of psychologists nationally. Actions taken or being taken to share learning across Greater Manchester. 1. Learning to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE. 2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums. 3. Regulation 28 Report and response to be shared with mental health commissioners in Greater Manchester to ensure that a review of older adult inpatient provision is undertaken. In conclusion, key learning points and recommendations will be monitored to ens ure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester. I hope this response demonstrates to you and Mr Tice family that NHS GM has taken the concerns you have raised seriously and is committed to work together as a system including our service users, carers and families to improve the care provided. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any f urther information. Yours sincerely Chief Nursing Officer NHS Greater Manchester Integrated Care 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
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