Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0012, written 11 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jan 2023 |
|---|---|
| Reference | 2023-0012 |
| Deceased | Lucy Jones |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| 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 THIS REPORT IS BEING SENT TO: Chief Executive, Aneurin Bevan University Health Board CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 29/03/2022 an investigation was opened into the death of Lucy Amanda Jones The investigation concluded at the end of the inquest on: 20/12/2022 The conclusion of the inquest was recorded as: Suicide The medical cause of death was: 1a Asphyxia 1b Hanging 1c) Mental Illness CIRCUMSTANCES OF THE DEATH 1 2 3 4 In 2019 Lucy Amanda Jones developed a serious mental illness which caused her to become stricken with paranoia. Despite receiving treatment and support, the problems she faced became overwhelming and on 12/03/22, Lucy took her own life by hanging at in Abergavenny. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: - 1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022. 2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone on only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy. No efforts were made to “cold call” when Lucy could not be contacted. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: 1. The steps that are being taken to ensure that patients who are so unwell to be detained under the Mental Health Act, do not have to wait for more than 2 years for psychological therapies. 2. The policy that determines what steps should be taken to ensure that mental health practitioners can be properly reassured about the health of their patients who are refusing or reluctant to engage. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 08 March 2023. I, the Coroner, may extend this 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 necessary COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Lucy Amanda Jones Health Inspectorate Wales. 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 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. DATE: 11 January 2023 Signed: 8 9 Caroline Saunders His Majesty’s Senior Coroner for the Area of Gwent.
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.
9th March 2023
Private & Confidential
Caroline Saunders
Senior Coroner (Gwent)
Dear Ms Saunders
Re: Regulation 28 Report received by Aneurin Bevan University
Health Board further to the inquest touching on the death of Lucy
Amanda Jones which concluded on 20.12.2022
I am writing to provide you with the Health Board’s response to the
Regulation 28 Report to Prevent Future Deaths, following the inquest into
the death of Lucy Amanda Jones.
As requested, the information presented below is intended to describe the
action taken / being taken to mitigate the risk of future deaths.
You require the Health Board to provide you with the following information:
1. The steps that are being taken to ensure that patients who are so
unwell to be detained under the Mental Health Act, do not have to wait
for more than 2 years for psychological therapies.
2. The policy that determines what steps should be taken to ensure that
mental health practitioners can be properly reassured about the health
of their patients who are refusing or reluctant to engage.
The discharge summary of 27 November 2019 following Miss Jones’
discharge from Talygarn acute mental health ward indicated that she was on
a waiting list with the psychology service for Cognitive Behavioural Therapy
for psychosis (CBTp). Each ward is allocated 1.5 days of a Senior
Psychologist – this was ringfenced funding provided by Welsh Government to
support the provision of psychological therapies in inpatient environments in
Bwrdd Iechyd Prifysgol Aneurin Bevan
Pencadlys,
Ysbyty Sant Cadog
Ffordd Y Lodj
Caerllion
Casnewydd
De Cymru NP18 3XQ
Ffôn: 01633 436700
E-bost: abhb.enquiries@wales.nhs.uk
Aneurin Bevan University Health Board
Headquarters
St Cadoc’s Hospital
Lodge Road
Caerleon
Newport
South Wales NP18 3XQ
Tel No: 01633 436700
Email: abhb.enquiries@wales.nhs.uk
Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board
mental health services. If someone were able to engage in psychological
therapy at that point it would commence with no waiting time. It is the case
that many people are not able to respond to or engage in psychological
therapies either within the acute phase of their illness or in an acute
environment. Psychologists in these roles therefore work with others in the
multi-disciplinary team to facilitate and advise on pathways to psychological
care in the community.
With regard to management of the waiting list, decisions regarding clinical
need and likelihood of clinical gain, as well as the needs of others on the
waiting list are made by the Principal Psychologist in each area who has
oversight of the waiting list and is a full member of the multi-disciplinary
team (MDT). This allows the service to expedite where appropriate.
The clinical notes indicate that Miss Jones was offered an appointment on 12
May 2021 with the psychology service, which she did not attend. This was
some 18 months after her discharge from Talygarn ward, though it is
acknowledged that there was a significant delay in offering appointments
due to the Covid pandemic, associated lockdowns and staffing issues
including redeployment and absences at this time. During this time, Miss
Jones was in touch with her Care Co-ordinator, a Social Worker within the
Community Mental Health Team (CMHT) who would have been able to liaise
with psychology colleagues in the team as required.
In regard to this particular case, since this time the Health Board has
invested further in psychological input to acute treatment areas and is
piloting a model of embedded psychological care which gives some provision
for outpatient follow-up. This allows for smoother transitions, increased
relational consistency (rather than needing to develop a new therapeutic
relationship with a different clinician), and more effective care pathways.
There is, of course, also the growth in the ‘Open Dialogue’ model of care (a
model of mental health care which involves a consistent family and social
network approach where all treatment is carried out via a whole
system/network meeting, which always include the patient) and this is being
provided by multi-disciplinary staff embedded in both acute care
environments and community provision.
In terms of future provision, the nursing strategy for the Adult Mental Health
and Specialist Services Directorate outlines the longer-term plan for a
consultant nurse post for psychological therapies and advocates nurses
training in the provision of evidence based psychological interventions. This
should also improve access along with the Health Education and
Improvement Wales (HEIW) commitment to training multiple disciplines in
quality assured psychological interventions by providing paid places on the
PGDip in CBT.
With regard to the policy that determines what steps should be taken to
ensure that mental health practitioners can be properly reassured about the
health of their patients who are refusing or reluctant to engage, the Adult
Mental Health and Specialist Services Directorate has developed a policy to
guide clinicians in their next steps when a person does not attend
2
appointments and/or further disengages with the team/service – the
Disengagement and Did Not Attend policy.
The policy seeks to explore and balance the clinician and team’s duty of care
to that patient along with the person’s right to refuse/decline treatment and
intervention - where the person has the mental capacity to make this
decision and there is no statutory power to compel this. The policy supports
clinical decision making based on the person’s needs, identified/known risks
and any information from others. It supports communication required with
the patient and others (where indicated) and the views of the multi-
disciplinary team, and advice for the patient i.e., routes back to the mental
health service should their mental health deteriorate.
The policy remains in draft at the moment with consultation due to end on
10 March 2023, and will then be ratified by the Division’s Quality & Patient
Safety meeting scheduled for 29 March 2023, with a view to this then being
considered and adopted by other Directorates in the Division which offer
secondary care services.
I trust that this information offers you reassurance of the actions taken by
the Health Board in respect of the issues raised. If any further information or
assurance is required, please do not hesitate to contact me.
Yours sincerely
Prif Weithredwr/Chief Executive
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