Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0029, written 26 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 | 26 Jan 2023 |
|---|---|
| Reference | 2023-0029 |
| Deceased | Zachary Klement |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Suicide (from 2015) |
| Organisation named | Surrey and Borders Partnership 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Zachary KLEMENT
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
•
Chief Executive Officer, NHS England and
NHS Improvement, PO Box 16738, Redditch B97 9PT,
England.contactus@nhs.net
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
The inquest into the death of Zachary KLEMENT was opened on 18th
March 2021. Evidence was heard between 4th and 6th October 2022, and it
was concluded on 2nd December 2022.
I found the medical cause of death to be:
1a. Suspension
I determined that Zachary took his own life by suspension during a crisis
of deteriorating mental health and increasing suicidal ideation. I recorded
a narrative conclusion, detailing the following:-
On 2nd March 2021, Zachary Klement was found suspended in his
bedroom at his supported living accommodation in Woking, Surrey, and
was pronounced deceased by attending paramedics at 19:37. He had a
long history of mental health issues from childhood and was diagnosed
with Autistic Spectrum Disorder, Emotionally Unstable Personality
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Disorder, general anxiety disorder and Bipolar Affective Disorder.
On 26th January 2021, Zachary was admitted to Farnham Road Hospital
as an informal patient following an escalation in his self-harm and
suicidal ideation. He was discharged back to his supported living
accommodation on 1st February 2021, initially under the care of the
Home Treatment Team and then the Community Mental Health
Recovery Service. He continued to have fluctuating mood and episodes of
self-harm, and he sought help from Safe Haven and the Psychiatric
Liaison Service at St Peter’s Hospital on 4th, 22nd, 24th and 28th February.
On the last occasion, 28th February 2021, he expressed concern he could
not keep himself safe. He requested inpatient admittance and then agreed
to Home Treatment Team care before changing his mind. On this
occasion his immediate risk was assessed as low and he was discharged
back to the Community Mental Health Team. This was a missed
opportunity to contain and manage his risk whilst exploring his needs.
The lack of availability of psychological therapies and resources tailored to
the needs of patients with Autistic Spectrum Disorder which could be
offered to Zachary by Surrey & Borders Partnership NHS Foundation
Trust also represented a missed opportunity to provide therapeutic care.
On the afternoon of 2nd March, Zachary sent a text message to his Care
Coordinator stating that he wanted to discharge himself from mental
health services as he felt they were not helping him. A support worker
found him suspended in his bedroom at around 18.45. Suicide.
4 CIRCUMSTANCES OF THE DEATH
Zachary was found suspended in the bedroom of his supported accommodation
on 2nd March 2021, and was pronounced deceased by attending paramedics.
5 CORONER’S CONCERNS
The MATTERS OF CONCERN are:
- Zachary had a history of mental illness from childhood. His
diagnosed conditions of Autistic Spectrum Disorder (ASD) and
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Emotionally Unstable Personality Disorder required care tailored
to his neurodiverse needs. Concern was expressed by two
Consultant Psychiatrists who cared for him in life, and the Court
appointed Expert Consultant Psychiatrist, regarding the lack of
consideration for those with neurodiverse conditions in the care
options available, and the lack of availability of appropriate
therapies;
Inpatient mental health units adversely affect
those with
neurodiverse conditions since they require calm and structure.
to patients with
There are no
neurodiverse conditions presenting in acute crisis;
inpatient options
tailored
-
- Home Treatment Teams do not offer continuity of staff or set
appointment times, as they are a crisis team allocated according to
demand. This stability is required by those suffering from ASD;
- There is a lack of availability of psychological interventions, being
the main treatment for neurodiverse conditions, including art
therapy, Dialectical Behaviour Therapy (DBT) and Systems
Training for Emotional Predictability and Problem Solving
(STEPPS) (Zachary was placed on a waiting list)
Consideration should be given to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See names in paragraph 1 above
2.
3. Surrey and Borders Partnership NHS Foundation Trust,
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4. The Chief Coroner
In addition to this report, I am 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 at the time of your response, about the release or
the publication of your response by the Chief Coroner.
Signed:
ANNA LOXTON
DATED this 26th day of January 2023
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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.
Ms Anna Loxton
HM assistant Coroner for Surrey
HM Coroner’s Court
Station Approach
Woking
GU22 7AP
Dear Ms Loxton,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
04 April 2023
Re: Regulation 28 Report to Prevent Future Deaths – Mr Zachary Klement who
died on 02 March 2021
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26
January 2023 concerning the death of Mr Zachary Klement on 02 March 2021. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Zachary’s family and loved ones. NHS England is
keen to assure the family and the coroner that the concerns raised about Zachary’s
care have been listened to and reflected upon.
We are aware across both the mental health and learning disability and autism
programmes that autistic people can have mental health conditions. Part of our
ongoing work is to ensure a greater understanding of the impact of autism on, and
better diagnosis for, both autism and the mental health conditions that autistic people
may have. We are working with the Royal College of Psychiatrists, and others, to
support best practice in diagnosis and treatment for mental health conditions for
people who are autistic.
The Health and Care Act 2022 made it mandatory for all staff in regulated services to
complete the Oliver McGowan mandatory Training to raise awareness of autism and
learning disabilities and to better equip staff to support people who are autistic.
It is a requirement of the Equality Act 2010 that public services make reasonable
adjustments for people who have a disability, and this includes people who are
autistic. These reasonable adjustments should be across inpatient, community
services and talking therapies for mental health services. Services need to ensure
that they are not discriminating against people because of their autism and should be
providing suitably adapted services.
Person centred services should always be delivered based on the individual’s needs
– autism does not present in the same way for every person and so services need to
meet everyone’s needs as they present.
We would always expect that people are offered the least restrictive and least
harmful option in terms of care, which may or may not be an inpatient stay. If an
inpatient stay is agreed to be the right option for an individual at any given time, then
reasonable adjustments should be made for that individual. However, all options
should be considered before an inpatient stay is decided upon. All inpatient units
should be places that meet the patients’ needs. The sensory-friendly resource pack,
which includes the Green Light Toolkit and the sensory guide, supports Trusts to
ensure that they meet the needs of people who are autistic. More broadly, we know
that the quality of the support provided to people with mental health problems,
including people with a learning disability and autistic people in inpatient settings,
can vary. In response to this, a new Mental Health, Learning Disability and Autism
Inpatient Quality Transformation Programme was established in 2022 to support
cultural change and a new bold, reimagined model of care for the future across all
NHS-funded mental health, learning disability and autism inpatient settings. More
information about this new programme of work is available here.
An overarching aim of the Long-Term Plan for Mental Health is to deliver
increasingly responsive services, to remove thresholds for access to care and to
embed a “no wrong door” mentality across mental health services. The funded
expansion and transformation of services through the Long-Term Plan should
support this important shift in clinical practice and it should no longer be the case
that an assessment of risk leads to a door being closed to a patient. There is clear
evidence that risk assessment tools are not an effective basis on which to predict
future suicidal behaviour and incidents of self-harm, and should therefore, not be
used as a basis for deciding whether to make care and treatment available for an
individual. Following the recently updated NICE guidelines for Self-harm:
assessment, management and preventing recurrence, NHS England wrote to all
Mental Health Providers in England emphasising that clinicians should not use risk
assessment tools, scales, or stratification approaches to predict future suicide or to
determine who should be offered treatment, or who should be discharged. To
support services to adhere to NICE guidance and to enable a definitive change in
clinical practice and culture, NHS England is working with NICE, the Department of
Health and Social Care (DHSC) and experts in suicide and self-harm prevention to
further develop evidence-based best practice in safety planning and the
management of needs and risks. This work is being co-produced with experts by
experience, local clinical leaders and in line with evidenced based practice.
Through the Long Term Plan, there has also been significant investment in Crisis
Resolution and Home Treatment teams, the majority of which are now open-access
and operating 24/7 in line with national expectations. While access and capacity has
improved significantly since 2017, we know variation in experience and outcomes
still exists, and in light of this the recently published Urgent and Emergency Care
Recovery Plan sets out that NHS England will support systems to build on the
expansion of Home Treatment teams for people with acute mental health needs, with
a clear focus on the quality of provision going forward.
Adapted therapeutic approaches can meet the needs of people who are autistic and
are suitable to support recovery. The national expectation is that people will access
therapies within a few weeks and that for people who are autistic these will be
reasonably adjusted using the above resources as guides.
We have also been assured that Surry and Borders Partnership NHS Foundation
Trust have taken time to assess training needs for staff and have undertaken a Trust
exercise in providing staff with autism training. All staff since June 2022 have
undertaken autism spectrum disorder (ASD) awareness training.
I would also like to provide further assurances on national NHS England work that is
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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