Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0282, written 12 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 | 12 Sep 2022 |
|---|---|
| Reference | 2022-0282 |
| Deceased | Daniel Nelson |
| Coroner | Nicholas Rheinberg |
| Coroner area | Lancashire and Blackburn with Darwen |
| Category | Alcohol, drug and medication related deaths · Other related deaths |
| Organisation named | Lancashire & South Cumbria NHS Foundation Trust · Greater Manchester Mental Health 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
, Chief Nurse and Director, Greater Manchester Mental Health
NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL
1
CORONER
I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Lancashire
and Blackburn with Darwen
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 21st May 2020 an investigation was commenced into the death of Daniel Robert
Nelson aged 37. The investigation concluded at the end of the inquest on 12th
September 2022. The conclusion of the inquest was that the deceased died as a result
of heroin toxicity, that his death was drug related and that failings of the Trust in relation
to among other things, section 117 obligations, contributed to the death.
4
CIRCUMSTANCES OF THE DEATH
The deceased had a long history of a dual diagnosis of schizophrenia and drug
dependency. Following years of homelessness and imprisonment he was sectioned
under section 3 of the Mental Health Act 1883 (“the Act”) and received treatment in the
Eagleton Ward of the Meadowbrook Unit in Salford. He was discharged from section 3
care with an inadequate discharge plan and the requirements of section 117 of the Act
were not met. He was housed in unsuitable emergency accommodation, without
adequate support, in circumstances where he had access to drugs and subsequently
died as a result of an accidental heroin overdose. The evidence revealed that with
proper discharge planning and care his death would probably have been avoided. Staff
on the Eagleton Ward had insufficient knowledge in relation to discharge planning and
duties, particularly where, as in this case, the discharge was to an area outside
Manchester. Within the Trust there was no protocol, policy or adequate standard
operating procedures governing section 117 discharges
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. –
Within the Trust there was no protocol, policy or adequate standard operating
procedures governing section 117 discharges
1
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 8th November 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 through their legal representatives:
the Probation Service, Lancashire and
South Cumbria NHS Foundation Trust and Greater Manchester Mental Health
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
Dated 12th September 2022 SIGNED Nicholas Rheinberg
Assistant Coroner
2
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.
PRIVATE AND CONFIDENTIAL Mr Nicholas Rheinberg Assistant Coroner for Lancashire and Blackburn with Darwen HM Coroner’s Court and Office Coroner's Court 2 Faraday Court Faraday Drive Preston Lancashire PR2 9NB 3rd November 2022 Dear Mr Rheinberg Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL Re: Daniel Nelson (deceased) Regulation 28 Preventing Future Deaths Response On behalf of Greater Manchester Mental Health NHS Trust (GMMH) I would like to offer Mr Nelson’s family our sincere condolences at this difficult time. Mr Rheinberg, thank you for highlighting your concerns during Ms Nelson’s Inquest which concluded on 12th September 2022. On behalf of the Trust can I apologise that you have had to bring these matters of concern to the Trust’s attention. Please see the Trust’s response in relation to the concerns you have raised, and the actions taken by the Trust: Within the Trust there was no protocol, policy or adequate standard operating procedures governing section 117 discharges. The Trust has a Section 117 Project Group that has developed a Section 117 Aftercare Policy that addresses responsibilities of services to someone who is subject to Section 117 of the Mental Health Act 1983 (MHA). The policy has been widely consulted upon and is due to be ratified at the Trust Mental Health Act and Mental Capacity Act Compliance Committee on 24th November 2022. Following ratification the policy will be shared with staff through the Social Care Leads in each division of the Trust. The policy will be uploaded to the Trust intranet and will be shared with staff through the Trust’s weekly communication briefing and the Trust Patient Safety Newsletter. In addition to the policy the Trust Section 117 Project Group has reviewed and updated the existing training in respect of Section 117 and staff responsibilities that will be delivered to staff on a quarterly basis. This group has developed training aimed at members of multi- disciplinary teams working in the Trust inpatient wards that is being delivered across all sites. The Trust’s clinical record, Paris, has been updated and now automatically displays a ‘flag’ to identify aftercare eligibility for those patients who have a history of detentions within GMMH. The flag will remain live on the person’s clinical record until Section 117 duties are ended via a formal review and Section 117 discharge process. Across GMMH learning from incidents to reduce the risk of reoccurrence is key. Learning events are either held locally within the team or division that the incident occurred and /or the Trust hold larger Trust wide learning events where the details and learning from either one incident or a group of similar themes identified are shared with staff across the Trust. These events are held monthly. On 16th December 2022 the learning event being delivered is Safe Discharge and 117 Responsibilities – a Salford case study where the learning from events surrounding Mr Nelson’s discharge and subsequent death will be shared along with resulting Trust developments. Following the event the learning is summarising in a briefing that is shared with staff and uploaded to the Trust’s Patient Safety intranet page. Mr Rheinberg, on behalf of the Trust can I thank you for bringing these matters of concern to the Trust’s attention. I hope this response demonstrates to you and Mr Nelson’s family that GMMH have taken the concerns you have raised seriously. If you have any further questions in relation to the Trust’s response, please do let me know. Yours Sincerely, Medical Director GMC 3548585
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