Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0356, written 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2022 |
|---|---|
| Reference | 2022-0356 |
| Deceased | Ami Mitchell |
| Coroner | Simon Fox |
| Coroner area | Avon |
| Category | Suicide (from 2015) |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS 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.
M. E. Voisin His Majesty's Senior Coroner Area of Avon 3rd November 2022 REF: 27343 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BE ING SENT TO: Avon & Wiltshire Mental Health NHS Trust 1 CORONER I am Dr Simon Fox Assistant Coroner for Area of Avon 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. httQ:LLwww.legislat ion.gov.ukLukQgaL2009L25Lschedu1eL5LQaragraQhL7 httQ:LLwww.legislation.gov.ukLuks iL2013L1629LQartL7Lmade 3 INVESTIGATION and INQUEST On 22/06/2022 an investigation was commenced into the death of Ami Louise Mitchell. The investigation concluded at the end of the inquest on 3rd November 2022. The conclusion of the inquest was Suicide. 4 CIRCUMSTANCES OF THE DEATH See below 5 CORONER'S CONCERNS During the course of the inquest the evidence revea led 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. - Ms. Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 until she hung herself on 31 May 2022. st Throughout this period she presented regularly and persistently with a) delusions; b) auditory hallucinations (including command); c) visual hallucinations; d) intrusive thoughts of killing her partner and children; e) her and her family requesting admission The Coroner's Cou rt, Old Weston Road, Flax Bourton, BS48 lUL Despite this a) No formal diagnosis was made; b) No escalation in management or admission took place. The Coroner's Court, Old Weston Road, Flax Bourton, 8S48 lUL 6 ACTION SHOULD BE TAl<EN In my opinion action should be taken to prevent future deaths and I believe you 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 by 29 December 2022. the coroner, may extend the period. 111 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: • the family of Ami Mitchell 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 03/11/2022 Signature Dr Simon Fox Assistant Coroner Area of Avon The Coroner's Court, Old Weston Road, Flax Bourton, BS48 lUL
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.
Dr Simon Fox
HM Assistant Coroner (Avon)
The Coroner's Court
Old Weston Road
Flax Bourton
BS48 1UL
Avon and Wiltshire
Mental Health Partnership NHS Trust
Bath NHS House
Combe Park
Bath
BA1 3QE
20 December 2022
Inquest into the death of Ami Louise Mitchell
Regulation 28 Report to Prevent Future Deaths
Dear Dr Fox
Thank you for the Regulation 28 letter you sent us dated 3 November 2022 regarding the
tragic death of Ami Mitchell who died on the 31 May 2022. We are very sorry that Ms.
Mitchell lost her life and we have accepted the findings of the internal report commissioned
following her death.
In the conclusion of the Inquest held 3 November 2022 you shared your concerns in regards
to lack of formal diagnosis and lack of escalation in management or in admission that took
place in Ms. Mitchells care and treatment.
The Trust has completed a review of the diagnostic processes for service users in South
Gloucestershire, which has in turn informed an action plan to address the improvements.
Lack of formal diagnosis
Our improvement in this area includes the assurance that that all service users receive a
diagnosis and formulation from which care and treatment is informed by the NICE guidance
appropriate for the diagnosis. In order to achieve this the trust must ensure the diagnosis or
working diagnosis is clearly recorded in the clinical record, that the diagnosis or working
diagnosis is discussed with the Service user and their family where appropriate and that
there should be a protocol to adhere to where there is a difference of opinion.
We have ensured that there is now a Consultant medical lead for diagnosis in the area of
South Gloucestershire and that this lead with senior support will work with the local team to
put in place a diagnosis, which has been discussed informed by best practice guidelines and
discussed with service user and their carer. We expect this progress on these actions to be
audited in 3 and 6 months of the implementation for internal assurance.
Lack of escalation in management or in admission
The trust will achieve improvement in this area in part by the previous improvement around
diagnosis, which will clearly support the escalation of a pathway. The Clinical lead for South
Gloucestershire will also ensure that all care and treatment plans (Crisis Plans) have a clear
expectation of management escalation including possible admission if relevant. This might
include clarity on escalation to admission if deemed appropriate.
I also believe that our ambitious Trustwide Strategy, currently out to consultation will direct
a wider improvement in pathway clarity.
The Clinical Strategy element of the Trustwide Strategy is underpinned by five principles
which have been created in consultation with patients and service users, staff and the wider
community. We have developed five priority pathways, Complex Emotional needs,
Dementia, dual diagnosis, neuro-development, and psychosis. The future of psychosis
services is an integrated pathway that is co-produced with service users and their carers,
delivering timely interventions with appropriate length treatments, to enable recovery. We
want to provide the best care, at the right time, through consistent services that are
accessible by all communities.
We aspire to be a prevention-focused, trauma informed service with renowned expertise in
early intervention for psychosis.
We attach the updated action plan for your information and will be happy to send you an
updated version six months from today, after completion and quality control.
Yours sincerely
Chief Executive
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