Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0209, written 22 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jun 2023 |
|---|---|
| Reference | 2023-0209 |
| Deceased | Stephen Richardson |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Mental Health related deaths |
| 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 NHS England & NHS Improvement (PFDs) 2 Secretary of State for the Department of Health and Social Care, Mr S Barclay 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 04 October 2019 I commenced an investigation into the death of Stephen Norman RICHARDSON aged 47. The investigation concluded at the end of the inquest on 22 June 2023. The conclusion of the inquest was that: Stephen Norman Richardson died from the effects of a self-inflicted ligature , however his intention in doing so remains unclear as the evidence presented Stephen had a fear of dying by suicide. 4 i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. CIRCUMSTANCES OF THE DEATH The Jury found, Self-inflicted ligature on 24th September 2019 at Sid Watkins Unit. Stephen Norman Richardson is a male who was 47 years of age at his time of death. Stephen had suffered with treatment resistant paranoid schizophrenia, from the age of 18. Following a number of medications being unsuccessful in managing Stephen's condition and also a long period of inpatient treatment, Stephen was prescribed clozapine in 2006. Clozapine allowed Stephen to live independently and be able to mostly manage his mental well-being. Stephen was regularly monitored by blood testing and in 2018, he had a number of results which concluded that clozapine could no longer be used to treat Stephen's condition. The Jury have reached the conclusion that it was reasonable to stop the clozapine at this time. However, the Jury are of the view that there were missed opportunities to treat the neutropenia with a view to restart clozapine and also no exploration of whether other medication that Stephen was prescribed could have been the cause of his neutropenia, rather than clozapine. Almost immediately following clozapine being stopped Stephen's mental health deteriorated. On the 20th May 2018 there was a marked deterioration in Stephen's mental health. A schedule of daily visits was put in place in recognition of this. On 24th May 2018 there was a further deterioration in Stephen's mental health. The view at this time was that Stephen met the criteria to be sectioned under the Mental Health Act. However, he was not sectioned at this time and the Jury heard that this was due to no bed being available on an acute mental health unit. Stephen was advised that the plan for him was to be admitted to hospital 2 days later. A plan was put in place for the community crisis team to visit Stephen at his home at least twice a day. On the 26th May 2019 Stephen was still not admitted or sectioned under the Mental Health Act. Visits from the Mental Health Team had not been completed as previously discussed. On May 29th Stephen was visited and the conclusion from this visit was that Stephen should be Regulation 28 – After Inquest Document Template Updated 30/07/2021 xiii. xiv. prioritised for admission. Later on that day Stephen attempted to hang himself. The Jury are of the conclusion that the failure to secure a bed on an acute Mental Health Unit for Stephen was a gross failure that contributed to the attempted hanging. Furthermore, this failure also contributed to Stephen sustaining a hypoxic brain injury, and the damage he sustained to his throat, which resulted in Stephen needing to be peg fed. xv. Whilst as an inpatient at the Royal Liverpool Hospital, Stephen's behaviour became cause for concern, , Stephen said that it fell out of his pants. was found outside Stephen's room, when asked this resulted in the plan for Stephen being that he would be admitted to Clock View rather than the Brain Injury Unit, A bed was found on 28th June 2019. Stephen became an inpatient at Clock View 2nd July 2019. Stephen was viewed as having a settled period at Clock View. On 11th July 2019 Stephen was transferred to the Brain Injury Unit, this was described as an emergency transfer due to the need for his bed to be used by another patient. The Jury are in agreement with Stephen's family in that this transfer was not in Stephen's best interest, as there had been no plan of care established for Stephen at the time of transfer. Whilst being an inpatient at the Brain Injury Unit, there were incidents of Stephen assaulting staff. Due to these incidents Stephen was returned to Clock View on 24th July 2019. On 14th August 2019 about the Following this incident a written record was made and the information was verbally shared at the start of the handover. However there was no alteration to Stephen's risk assessment. In addition to this there was no safeguarding plan implemented to reflect the incident and any possible related risks. The jury have noted that, prior to the cord being found Stephen had requested to call his mother. Following Stephen being unable to contact his mother the cord was found. The jury have concluded that non-completion of the risk assessment document was in itself a significant failure. On discussion of a transfer back to the Brain Injury Unit family shared concerns as to the ligature risks, and the loss of protective factors such as familiarity with his surroundings and staff. At the unit family were also in disagreement with a transfer to the Brain Injury Unit at this stage due to their views that the physical environment at the unit being a risk to Stephen. Following an assessment of Stephen a phased transfer plan was proposed. The Jury have concluded that this was a significant failure in that this plan was not communicated to relevant persons. In addition to this the Jury conclude that in the one instance that the plan was shared it was misunderstood by bed management. This is viewed by the jury as a missed opportunity for Stephen. Despite the proposed phased return to the Brain Injury Unit and the concerns raised by the family Stephen was transferred with immediate effect on the 16th September 2019. Between 7th September 2019 and the 25th September 2019, no risk assessment was completed either by Clock View or the Brain Injury Unit. The Jury concluded that this was a serious missed opportunity as there was an absence of documentation to inform care planning and safeguarding steps for Stephen. Documentation that was completed for Stephen prior to 24th September 2019 recorded occasions of Stephen having suicidal thoughts. It is also documented that Stephen had a recognition of his thoughts at this time and requested support in an effect to keep himself safe. On the day of the ligature incident (24th September) observations from ward staff state that he was settled, watched TV, spent time in his room, showered, went shopping and wash and dried his clothes. Stephen's sister also visited him that evening. Following the staff handover on the ward, Stephen's observations show that there was a change in Stephen's presentation. He is noted as refusing his medication, refusing access to his room and throwing an item around his room. Stephen is also recorded in observations as being anxious. The Jury heard in evidence that there was no qualified mental health nurse on shift working that evening. Stephen's behaviour continued and a decision was made to allow him to have time to calm down. At 23:20 Stephen spoke to staff to request that he could make a telephone call to his mother. Stephen was bare chested and he was asked to put a top on but refused to do this. At 23:40 Stephen repeated his request to call his mother again. He was told that he could use the phone in the office, but refused and said that he had changed his mind, saying it did not matter. xvi. xvii. xviii. xix. xx. xxi. xxii. xxiii. xxiv. xxv. xxvi. xxvii. xxviii. xxix. xxx. xxxi. xxxii. xxxiii. xxxiv. xxxv. Regulation 28 – After Inquest Document Template Updated 30/07/2021 xxxvi. xxxvii. xxxviii. xxxix. xl. xli. xlii. A short time later staff noticed that Stephen's room was in darkness. A light on a mobile phone was shone into the room, This was in an attempt to see where Stephen was in the room. The door of Stephen's room was found to be barricaded and the jury heard in evidence that it took 4 - 6 minutes to clear the barricade and enter the room. Evidence was also given that no noise was heard at any time of Stephen barricading his bedroom door. On entering the bedroom, Stephen was found ligatured behind the bathroom door. It has been discussed in court that the procedure to be followed at the Brain Injury Unit in such circumstances is to call 2222 and 999 to alert emergency services. Although staff called 999 at 23:53 no call was made to 2222. The Jury have concluded that there were missed opportunities due to there being no knowledge of the correct procedures to follow. However it is acknowledged that this failure would not have altered the outcome for Stephen. The Jury also conclude that lack of communication between persons on duty was a failure to respond appropriately to Stephen's behaviours. For example, there was no information shared as to the sharing of the incident could have allowed for additional risk planning. As a jury we would like to offer Stephen's family our sincere condolences. Stephen was transferred to ICU at University Hospital Aintree on the 24th September 2019 and sadly passed on 28th September 2019. As a result of his extensive brain damage the decision was made by his family to withdraw his life support. Stephen was pronounced dead.” being found 4 weeks earlier. The 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) It was clear from the investigation that at the time of Stephen ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient. The evidence heard has confirmed that that parlous situation has not improved. 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 August 17, 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 North West Ambulance Service NWAS Merseycare NHS Trust I have also sent it to Regulation 28 – After Inquest Document Template Updated 30/07/2021 Living with Shizophrenia MIND Richmond Fellowship 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: 22/06/2023 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.
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health & Social Care 39 Victoria Street London SW1H 0EU 9 May 2024 André Rebello OBE Senior Coroner HM Coroner's Court Gerard Majella Courthouse Boundary Street Liverpool L5 2QD Dear Mr Rebello, Thank you for your Regulation 28 report to prevent future deaths dated 27 June 2023 about the death of Stephen Norman Richardson. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Stephen’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter and I am grateful for the extension you have granted. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission. Your report raises concerns over the availability of acute pyschiatric beds to treat patients in the community suffering with serious mental disorders requiring inpatient treatment. I understand that NHS England, in conjunction with Cheshire and Merseyside Integrated Care Board, has already carefully considered the matters of concern in your report and has provided you with a comprehensive response setting out the actions being taken to improve care quality and patient safety and on the specific concern around availability of beds. From a national perspective I would add that, under the NHS Long Term Plan, the NHS forecasts that, between 2018/19 and 2023/24, spending on mental health services has increased by £4.7 billion in cash terms, compared to the target of £3.4 billion set out at the time of the NHS Long Term Plan in 2019. This includes introducing new models of care in the community as part of the community mental health framework, which is replacing the care programme approach. These models of care provide improved access to a wide range of services including improved physical health care, trauma-informed care, and support for those with self-harm and substance misuse problems, giving adults with severe mental illnesses greater choice and control over their care and supporting them to live well in their communities, avoiding the need for an inpatient admission where possible. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD
Mr Andre Rebello
Senior Coroner
Liverpool and the Wirral Coroner’s Service
Gerard Majella Courthouse
Boundary Street
Liverpool
L5 2QD
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
13 September 2023
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Stephen Norman
Richardson who died on 28 September 2019.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 22
June 2023 concerning the death of Stephen Richardson on 28 September 2019. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Stephen’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Stephen’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 to Stephen’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.
In your Report you raised the concern that there was a national shortage of acute
psychiatric beds to treat patients in urgent need of immediate mental health
assessment and care as an inpatient, and that the situation has not improved since
Stephen’s death.
Mental health services have long been under significant pressure and there has
recently been a 30% increase in referrals to community services since before the
Covid-19 pandemic. NHS urgent and emergency care (UEC) are also treating record
numbers of patients, while delays in discharging patients who are clinically ready to
be discharged from hospital is affecting how quickly patients can access local mental
health beds.
In some local areas there is a genuine need for more beds, however, this should
always be considered as part of whole system transformation to reduce overall
reliance on hospital-based care. This is supported by the NHS Long Term Plan (LTP),
which committed to an additional £2.3bn funding invested in to mental health services
from 2019/20 – 2023/24. Around £1.3bn of that funding is for adult community, crisis
and acute mental health services to help adults get quicker access to the care they
need and prevent avoidable deterioration and hospital admission.
NHS England is also investing £36m over three years to improve the quality of mental
health, learning disabilities and autism inpatient settings. This includes a culture of
care improvement programme which is being co-produced with patients, carers and
families with lived experience. The programme is identifying opportunities to
strengthen family/carer voice in patient care, including risk management of suicide and
self-harm, and safety planning.
NHS England has also engaged with Cheshire and Merseyside Integrated Care Board
(CM ICB) regarding Stephen’s case.
The incident was reported to Liverpool Clinical Commissioning Group (LCCG) as a
Serious Incident (SI) in 2019 in line with The Serious Incident Framework (2015) and
was subsequently investigated by Mersey Care Foundation Trust (MCFT) and
Liverpool University Hospital Foundation Trust as part of a joint investigation. A Route
Cause Analysis (RCA) was undertaken with a subsequent action plan being produced
to acknowledge and support required learning/improvement. The action plan
incorporated several actions linked to safer bed management and patient placement
with sufficient assurance being provided by the relevant Trusts.
The Trust actions linked to bed management are:
• Ensuring all staff are aware of the correct process to follow when Mental Health
Assessment is required. Confirm and reinforce with staff how practitioners can
be supported to manage risk in the community where beds are unavailable, but
risk is considered high.
• To ensure that the process for escalation is reflected in the appropriate Trust
policy, whether that be the Crisis Resolution Home Treatment Standard
Operating Procedure or an alternative document so that practitioners are clear
on how they can ensure that bed managers are aware of their opinion that
priority should be given for a Patient for admission.
From a CM ICB perspective wider bed management/availability issues are being
continually addressed. Both locally and nationally there remains constant pressure on
acute psychiatry bed availability. In Liverpool, work continues to be undertaken with
system partners within the MCFT footprint to transfer those clinically ready for
discharge in a safe and timely manner to free up acute psychiatric bed capacity. Work
is also being undertaken at ICB level around delays.
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
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