Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0408, written 19 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2022 |
|---|---|
| Reference | 2022-0408 |
| Deceased | Mollie Stansfield |
| Coroner | Paul Marks |
| Coroner area | East Riding and Hull |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive of NHS England 2. The Chief Coroner 3. The President of the Royal College of Psychiatrists 4. The President of the Royal College of Nursing 5. All Interested Persons 6. The Chief Executive of NHS Scotland 7. The Chief Executive of NHS Northern Ireland A CORONER I am Professor Paul Marks, Senior Coroner, for the Coroner Area of East Riding of Yorkshire & City of Kingston Upon Hull 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 12th July 2019 I commenced an investigation into the death of Mollie Rose Stansfield, age 22 years. The investigation concluded at the end of the inquest on 9th December 2022. The conclusion of the inquest was: NARRATIVE - Mollie Rose Stansfield was born on 6th January 1997 in Hull and died on 10th July 2019 on Princes Quay, , Hull after falling . She suffered multiple injuries as a result of this fall which resulted in her rapid death. She had an underlying diagnosis of Emotionally Unstable Personality Disorder, as well as a history of drug and alcohol abuse. She was admitted to the Avondale Unit on 27th June 2019 as an informal patient, after being transferred there following presentation to Hull Royal Infirmary with a self-inflicted neck wound which was appropriately treated. Whilst there she absconded and purchased a number of tablets, which she took, but did not tell the nursing staff who discovered it later that day. She was transferred back to Hull Royal Infirmary and treated for this overdose. Upon her return to the Avondale unit she became physically unwell and was sent back to Hull Royal Infirmary for investigation of what was thought to be a cardiorespiratory problem. This was refuted and it is likely that her physical symptoms were due to the systemic toxic effects of cocaine. She absconded from the ward on a number of other occasions and whilst absent, which she took. She suffered a fit as a result of sourced taking but recovered. A Section 5.2 Mental Health Act order was put in place, but was probably not valid at material times. She was discharged to step down accommodation following being declared medically fit and following assessment by a psychiatrist. She was evicted from the step down accommodation on 10th July following an altercation the previous evening, and 1 went to a high rise block of flats with the intention of jumping off. Her friend however intervened, called the police who attended the flats and removed her to a place of safety, Miranda House, under Section 136 of the Mental Health Act 1983. Following a mental health assessment at 13:00 on 10th July she was found neither to be psychotic nor intoxicated with following her discharge and went to Princes Quay and fell to her death . She subsequently took The effects of may have clouded her judgment but equally the text message exchanges prior to her assessment at the Section 136 suite and after her release suggested that she intended to take her own life. 4 CIRCUMSTANCES OF THE DEATH See section 3 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. – There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect. Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid. Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you as Chief executive of NHS England have the power to take such action. Training and highlighting of this important power should be regularly delivered to all doctors and nurses about their respective holding powers. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 13th February 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 2 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (Williamsons – represented the Family) and NHS Teaching Hospitals Trust). I have also sent it to: Executive of NHS England), Psychiatrists), (President of the Royal College of Nursing), (Clyde & Co – represented Humber), (President of the Royal College of (Capsticks – represented (Chief (Chief Executive of NHS Scotland) and Northern Ireland) who may find it useful or of interest. (Chief Executive of NHS 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 19th December 2022 HM SENIOR CORONER 3
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.
From the Permanent Secretary and HSC Chief Executive Jael Hepworth-Etherington Coroner’s Assistant HM Coroner’s Office Castle Buildings Upper Newtownards Road BELFAST, BT4 3SQ Date: 27 March 2023 Dear Jael Thank you for your letter and the enclosed copy of the Regulation 28 Report for Ms Mollie Stansfield by HM Senior Coroner, Professor Paul Marks. I apologise for the delay in responding. Firstly, I would wish to place on record my sincere condolences to Ms Stansfield’s family following this very tragic incident. I have noted the findings of the coroner’s report, and in particular the concerns raised around the implementation of Section 5(2) of the Mental Health Act 1983. The equivalent Northern Ireland legislation is the Mental Health (Northern Ireland) Order 1986, and the equivalent Articles within the 1986 Order to sections 5(2) and 5(4) of the 1983 Act are Articles 7(2) and 7(3) respectively. Having considered the findings of the report, I agree with the importance of ensuring that Health and Social Care Trusts and relevant health practitioners here should be reminded of the powers under the Mental Health Order for the detention of patients. I am therefore taking steps to raise this issue with HSC Trust Chief Executives and relevant professional bodies, in order to ensure that the appropriate action is taken to address this point. Yours sincerely
Professor Paul Marks
Senior Coroner
East Riding of Yorkshire & City of Kingston Upon Hull
Coroner’s Service
The Guildhall
Alfred Gelder Street
Hull HU1 2AA
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
21 March 2023
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Mollie Rose Stansfield
who died on 10 July 2019
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 9
December 2022 concerning the death of Mollie Rose Stansfield on 10 July 2019. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Mollie’s family and loved ones. NHS England are
keen to assure Mollie’s family and the coroner that the concerns raised about Mollie’s
care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Mollie’s family or friends. I realise that
responses to Coroner Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones and appreciate
this will have been an incredibly difficult time for them.
Following the inquest, you raised concerns in your Report regarding awareness and
understanding of Section 5(4) of the Mental Health Act (MHA) 1983 and the
importance of delivering regular training to all doctors and nurses about their
respective holding powers. I hope that this response provides you with the assurances
that NHS England (NHSE), together with Health Education England (HEE), who have
contributed to this response, are providing the required guidance and training to all
medical professionals who hold these important powers.
In the case of consultant psychiatrists using the above powers, they are General
Medical Council (GMC) specialist registrants and must undertake a modular route that
is moderated via an approvals panel before they are eligible to implement Section 5
(2), if they have not attained approval prior to gaining their Certificate of Completion of
Training.
The 2007 amendments to the MHA 1983 also introduced the roles of approved
clinician and responsible clinician,1 enabling mental health professionals who are not
psychiatrists to carry out duties previously performed only by psychiatrists. The
introduction of these roles was intended to deliver enhanced quality of care while also
ensuring the best use of a skilled and professionally diverse workforce.
All newly qualified doctors in the UK complete a two-year Foundation Programme of
training. The curriculum specifically states that Foundation Doctors also need to
develop skills in managing clinical scenarios where they may be required to apply the
MHA 1983 (or equivalent, e.g., Mental Health Scotland Act 2015), including but not
limited to section 5(2). The training is delivered in the doctors’ workplace and is
overseen by the UK Foundation Programme and the GMC.
The use of Section 5(4) of the MHA 1983 is limited to specific nurses, referred to in
the act as nurses of the ‘Prescribed Class’ which means mental health and learning
disability nurses only. 'Prescribed Class’ nurses must undergo pre-registration training
in field-specific content in relation to the law, which will include these holding powers.
HEE are also currently working with the Department of Health and Social Care as part
of plans being developed to ensure that, as the current MHA is refreshed and revised,
there is a clear training offer for these nurses to ensure that they are clear about their
responsibilities in relation to section 5(4), as for other sections under the MHA.
To provide further capacity and enhance patient experience, HEE provides learning
opportunities for non-medical staff permitted to implement Section 5 (2) of the MHA
i.e. nurses (mental health or learning disabilities branches only), clinical psychologists,
social workers, and occupational therapists. This learning is in the form of access to
Higher Education Institute provided Mental Health law modules and employers are
provided with 18-24 months’ part-time salary support to enable the employee’s release
to gain the experiential learning that they must compile into a mandatory portfolio of
evidence that will be presented to an approvals panel, before they are allowed to
exercise the power of section 5(2).
In order to enable additional further capacity, HEE is also currently undertaking a pilot
to allow Specialty and Associate Specialist (SAS) doctors to gain competence via the
same portfolio route as non-medical staff. SAS doctors are employed in the NHS in a
non-training post and will have at least seven years’ experience of working in
psychiatry, four of which at a senior level.
Further to this, employers have an obligation to ensure that their staff are adequately
trained. We have been informed by Hull University Teaching Hospitals (HUTH) that
they have taken several learning opportunities from this unfortunate tragic incident.
This includes delivering several training and awareness sessions to senior nursing
teams on mental health and, in August 2022 and creating a five-year Mental Health
1 An approved clinician is a mental health professional approved by the Secretary of State or a person
or body exercising the approval function of the Secretary of State. Some decisions under the Mental
Health Act can only be taken by people who are approved clinicians. All responsible clinicians must be
approved clinicians. A responsible clinician is the approved clinician with overall responsibility for the
case. Certain decisions (such as renewing a patient’s detention or placing a patient on a community
treatment order) can only be taken by the responsible clinician.
Learning and Disabilities and Autism Strategy which is underpinned by an operational
delivery plan and highlights training as a key area of focus. This is monitored by the
Mental Health, Learning Disability and Autism Committee, and the Trust Board Sub-
committee, the Quality Committee.
I would also like to provide further assurances on national NHSE work taking place
around the Reports to Prevent Future Deaths. All reports received are discussed by
the Regulation 28 Working Group, comprising Regional Medical Directors, and other
clinical and quality colleagues from across the regions. This ensures that key learnings
and insights around preventable deaths are shared across the NHS at both a national
and regional level and helps us pay close attention to any emerging trends that may
require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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