Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0381, written 25 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2022 |
|---|---|
| Reference | 2022-0381 |
| Deceased | Philip Battle |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 North West Ambulance Service NWAS 2 Director of Public Health Prof. 3 Chief Constable 4 Police And Crime Commissioner 1 CORONER I am Andre REBELLO, Senior Coroner for the coroner area of Liverpool and Wirral 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 25 July 2022 I commenced an investigation into the death of Philip John BATTLE aged 73. The investigation concluded at the end of the inquest on 25 November 2022. The conclusion of the inquest was that: Mr Battle died by suicide 4 CIRCUMSTANCES OF THE DEATH Philip John Battle lived in warden supervised sheltered accommodation. On the 8th July 2022 he phoned the North West Ambulance service at 11.20. The call indicated an overdose and self-harm by hanging. From the triage protocol then in use this was graded as a category 3 response. This should have resulted in a response within 120 minutes. An ambulance arrived at his secure flat at 15.08 and found Mr Battle had died. He had a ligature around his neck 15.10. It remains unclear as to at what time Mr Battle died. . He was certified as having died at 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken and overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service Regulation 28 – After Inquest Document Template Updated 30/07/2021 in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future. The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 January 20, 2023. 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 The family of Mr Battle I have also sent it to the two main NHS mental health providers in Merseyside Mersey care NHS Foundation Trust and the Cheshire and Wirral Partnership NHS Foundation Trust who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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: 25/11/2022 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Andre REBELLO Senior Coroner for Liverpool and Wirral Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
André Rebello OBE Senior Coroner Liverpool and Wirral Area SK/HJF 20 January 2023 Dear André I am responding to your recent correspondence pertaining to the death of Mr Battle. I note that you are inviting Merseyside Police and NWAS to consider joint operability of mental health triage cars. I understand that you have heard evidence as to the existence of a joint operability programme in Blackpool but were unaware of the services available in Merseyside. Within the Merseyside Police force area the force has three mental health triage cars. At the time of writing these cars operate as follows: • Wirral Car - 7 late shifts (12.00-00:00 hrs) & 3 day shifts Tuesday, Wednesday & Thursday (0800-1600) • St Helens and Knowsley car - 7 late shifts (1500-0100). Day shifts are currently suspended due to staffing issues on NHS side • Liverpool and Sefton - 7 day/late shifts a week 1030-0100. The Liverpool and Sefton car addressed 53.4% of demand across the force. In considering our response we sought to understand from Lancashire Constabulary how the joint operability model works in Blackpool and have been informed as follows:- Synergy is commissioned by Local Integrated Care Board (ICB, the new name for NHS Commissioners), and covers Blackpool and Fylde & Wyre operating 1600 – 0000, 7 days a week. The car is staffed with a Response Officer, Paramedic & Mental Health Practitioner. The Synergy car can respond to mental health related police incidents and NWAS mental health related incidents. Which agency’s incident the car responds to, is decided by the staff in the car at the time. Therefore, the Synergy model does not mean that the police (in company with a MH practitioner) are servicing NWAS incidents (and vice versa). What it does mean is that, often at incidents there is a professional that is not required e.g. an NWAS incident with no policing purpose has an officer attend with NWAS and the practitioner. Synergy does not have a written remit and Lancashire Constabulary do not have data to identify the split in demand between police/NWAS incidents that it deploys to. Chief Constable Lancashire Police have stated that if they were informed of a case similar to that of Mr Battle and NWAS have it as a Cat 3 and have not identified any threat to life, there is no requirement for the police. In my view the way to address this issue would be through the information gathered and the risk assessment during the initial call to NWAS. Merseyside Police when setting up this service and indeed though review of the service and best practice, have looked at and considered inter-operability models with NWAS, however, they are not considered within this area to be the best use of personnel, as effectively it would lead to a vehicle crewed by three personnel, one of whom would almost always be surplus to requirements and indeed I would suggest that there will be more resource available if the current model is maintained. I am aware that in Merseyside, NWAS have emulated the police model and they have three designated cars for Merseyside. I am aware that the cars have funding for 7.5 hours per day but it is the aspiration of the NWAS trust to operate them 12 hours per day. I understand the hours of deployment are 0800 – 2000 Monday to Thursday and 1000 – 22.0 Friday to Sunday. When both the NWAS cars and the Merseyside Police cars are on duty there is communication between the practitioners in the vehicles so that the most clinically effective use of resources can be made. As you may be aware the demand on all of the emergency services has led to a nationally advocated Right Care Right Person model being developed. The adoption of this model means the appropriate state agency is deployed and that each of police, NWAS etc resources can be deployed as appropriate. In this case based on the information that the police have from your report there would not have been a requirement for police attendance. Merseyside Police are committed to working effectively with Blue Light partners, however, having considered the issues and discussed them with NWAS we do not believe that a joint operability model is appropriate for the Merseyside communities that we serve. Yours sincerely Chief Constable Chief Constable
LADYBRIDGE HALL 399 Chorley New Road Bolton BL1 5DD T: 0345 112 0999 nwas.nhs.uk Andre Rebello HM Senior Coroner Liverpool and Wirral BY EMAIL ONLY 23 January 2023 Dear Mr Rebello, Regulation 28 report Thank you for your letter dated 25 November 2022 sent following the conclusion of the inquest touching the death of Mr Battle. I know that you will share my response with Mr Battle’s family and I firstly want to express my sincere condolences to his family. NWAS’ core purpose is to save lives, prevent harm and offer services which optimise the likelihood of positive patient outcomes. It is of deep regret that on this occasion NWAS was unable to attend to Mr Battle as quickly as it should have and I am extremely sorry for that. NWAS takes all adverse events very seriously and it undertook an internal investigation into the attendance on Mr Battle. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. By this letter, I will address that concern as far as I’m able to do so. Shared resources between Merseyside Police and NWAS. Through the oral evidence that was before you during the inquest, you are aware that in other areas of the North West region there are initiatives in place for NWAS, a mental health service and a local Police force to share a mental health triage car. As you correctly identify in your report, those arrangements do not exist in Liverpool. However, the Psynergy model to which you refer is the only model of its type within the North West Region and is reflective of the particular demands of that geographical area. The NHS long term plan (2019/20 to 2023/24) makes a commitment to pursuing an ambitious transformation of mental health care, including the improvement of ambulance responses to those patients who need urgent and emergency assistance in respect of their mental health. Indeed, initiatives such as mental health response vehicles form part of this model of improvement. The NHS Long Term plan is clear in its recommendation that the response to mental health problems (including response vehicles) is to be health led as they are health related issues. In the financial year ending 2022/23, NHSE released an amount of capital funding for which ambulance trusts, in partnership with their regional Integrated Care Board (“ICB”) and local mental health trusts, have tendered in order to purchase the mental health response vehicles. The staffing for such response vehicles is separately funded through the Mental Health Investment Standards, which is attached to the NHS Long Term Plan. Within the North West, the scope, specification and operating model of the mental health response vehicles is reviewed and agreed by a pan North West steering group, chaired by the NHSE regional mental health lead, which includes all of the regional ICBs, NWAS and mental health trusts. It is necessary to work together in partnership with one another in order to achieve the commitments made within the NHS Long Term Plan. Police forces have similarly introduced response vehicles in order to provide further assistance to individuals with mental health needs but in relation to policing matters, for example, for the purpose of detection and prevention of crime and reducing the number of patients inappropriately detained under s136 Mental Health Act. Funding for these police vehicles is not derived from the Department of Health and Social Care/NHS but via the local Police and Crime Commissioner. You have asked that NWAS, Merseyside Police and the local mental health trusts work together in concert and share community mental health crisis intervention resources for the good of the community. NWAS and Merseyside Police provide each other with invaluable support and assistance on a daily basis. However, the demands faced by each service are very different, as too are the nature of the calls meaning that the call triage systems, categorisation and dispatch processes are distinct from each other. It is crucial that the respective mental health response vehicles reflect and meet the needs of the two very different services. NWAS, Merseyside Police, local authorities and the local mental health trusts are members and participants of the Crisis Concordat which collectively reviews mental health demand, incidents, local systems and practices in order to improve the outcomes for patients with mental health needs in the local communities. The Crisis Concordat brings together local authorities, mental health trusts and the emergency services into one environment. Through the Crisis Concordat, a suite of mutual training and education sessions have been introduced which are continuing. All participants of the Crisis Concordat are committed to working together to improve the outcomes for the local community. Beyond the Crisis Concordat, NWAS and the Merseyside Police come together again at the Regional Police Forum at which strategic, operational challenges and collaborative working opportunities are identified, discussed and agreed. NWAS has recommended that the incident involving Mr Battle be tabled for further discussion at the next forum. Should any further learning be identified at that forum, I would be very happy to share that with you if it would assist. I am sorry that you felt it necessary that there was cause to issue a Regulation 28 report and I hope that, by this letter, I have addressed your concerns. Should you require any further clarification or information, please do not hesitate to contact me or the Trust’s Head of Legal Services, Yours sincerely, Chief Executive
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