Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2023-0220, written 9 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Feb 2022 |
|---|---|
| Reference | 2023-0220 |
| Deceased | Michelle Jennings |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health & Social Care Secretary of State at Ministry of Justice 1 CORONER I am Alison Mutch , Senior Coroner, for the Coroner Area of Greater Manchester South 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 6th October 2020 I commenced an investigation into the death of Michelle Louise Jennings. The investigation concluded on the 24th November 2021 and the conclusion was one of suicide. The medical cause of death was 1a hanging 4 CIRCUMSTANCES OF THE DEATH Michelle Louise Jennings had a history of contact with mental health services and had a history of indicating suicidal ideation to a number of agencies. She was assessed as being suitable for step 4 therapy. However at the time of the assessment of her need there was a 2 year waiting list to access therapy. On the balance of probabilities this delay possibly contributed to her death. On 11th April 2019, 17th July 2019, 28th July 2019, 17th January 2020 and 8th May 2020 she was dealt with by British Transport Police (BTP) and indicated suicidal thoughts. Following the incident on 8th May 2020 BTP prosecuted her for obstructing the railways when she had indicated she had suicidal ideation at the time she was on the railway. She was subsequently arrested on a warrant and held in custody before being sentenced. On the balance of probabilities this decision to prosecute possibly contributed to the deterioration in her mental health and her subsequent death. On 1st August 2020 following calls to the mental health crisis line she was referred for a mental health assessment by the Primary Care Mental Health Team (PCMHT) part of Cheshire & Wirral partnership NHS Trust (CWP). On 3rd September 2020 she was assessed by telephone by the PCMHT and then the case was referred to the PCMHT MDT. On 6th September she rang Cheshire Police from Delamere Forrest with suicidal 1 thoughts. She was taken to Hospital and discharged the following day. On 9th September 2020 her case was considered by the PCMHT MDT. They determined her needs were too complex for the PCMHT and she was to be referred to the Community Mental Health Team (CMHT) part of CWP. The referral was not made until 16th September 2020. At the point of referral she was discharged from the PCMHT caseload. On 17th September 2020 she presented at Stepping Hill Hospital with suicidal thoughts. She was assessed by mental health services and discharged. On 23rd September 2020 she was discussed at the CMHT MDT where the referral was rejected and she was to be referred back to the PCMHT. She was discharged from the CMHT caseload at that point. She was no longer on the caseload of either the PCMHT or the CMHT. Despite the complexity of her needs and her deteriorating mental health there was no discussion between the PCMHT and the CMHT in relation as to how to manage or mitigate the risk at this point although it was documented that she felt rejected by mental health services. On the balance of probabilities the poor communication between the PCMHT and the CMHT, the failure to assess risk effectively to ensure she remained on the caseload of either the PCMHT or the CMHT probably contributed to the further decline in her mental health and her death. On 3rd October 2020 she made her way and hanged herself She was found on 5th October 2020. 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. – 1. The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time. Since that time the waiting period had not decreased and was now between 2 -3 years in both primary and secondary care. This was due to a shortage of trained therapists and demands on the service and was a national issue not specific to the CWP trust. 2. The inquest was told that the trust had since Michelle’s death recognised that the lack of ownership created through the application of its referral and discharge policy internally carried an unacceptable risk. Significant changes had been made. However it was unclear if nationally the lesson had been shared and that other mental health trusts had taken similar steps. 3. The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as Michelle. In Michelle’s case the BTP file reviewer (the nature of the offence Michelle faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of Michelle Jennings as required to. As a consequence a decision was taken to prosecute her without an assessment of the impact on Michelle and her case was dealt 2 with by the Magistrates Court without them being given the full background in relation to her deteriorating mental health. BTP are as a consequence of Michelle’s death taking steps to address how their prosecution teams should deal with the public interest test and gather information where mental health is an issue. However there is no clear mechanism for such learning and changes (to reduce the risk to life) in relation to vulnerable people such as Michelle to be implemented within the other 42 Police Forces in England and Wales or within other agencies responsible for prosecuting criminal offences. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6th April 2022. 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 namely the Family, Pennine Care, Cheshire & Wirral Partnership NHS, and Cheshire West & Chester Council who may find it useful or of interest. 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 Date 9th February 2022 Ms Alison Mutch HM Senior Coroner Manchester South 3
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.
From Maria Caulfield Parliamentary Under Secretary of State for Mental Health and Women’s Health Strategy 39 Victoria Street London SW1H 0EU 13 December 2022 Alison Mutch HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Thank you for your letter of 9 February 2022 to the Secretary of State about the death of Michelle Jennings. I am replying as Minister with responsibility for Mental Health and thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Jennings’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. With regard to access to mental health services, we know how vital timely mental health support is to ensure that a person does not experience a mental health crisis. We know that nationally there has been, and continues, to be a gap between the prevalence of mental health conditions and the ability of a person to access services. For many people in crisis, the NHS can, and does, provide lifesaving, life-changing care. Due to historical underinvestment, however, we are building from a low base in mental health care. This is why we are committed to increasing investment in, and improving access to, mental health services. Under the NHS Long Term Plan1, by 2023/24 mental health services will receive £2.3billion more than in 2018/19, which will mean that 2 million more people will have access to mental health services, including an additional 370,000 adults with severe mental illnesses. Through the Plan, we are improving joined-up working across the NHS and with other statutory services. Since April 2021, all areas are receiving significant additional, ring- fenced funding to develop fully integrated primary and community mental health services built around Primary Care Networks which includes improved access to psychological therapies, improved physical health care, employment support, 1 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf personalised and trauma informed care, medicines management and support for self- harm and coexisting substance use. By 2023/24, this investment will amount to almost £1billion extra per year for adults and older adults with severe mental illness. Twelve early implementer sites have been in receipt of ongoing transformation funding since 2019/20 to test new integrated models of primary and community mental health care in line with the Long Term Plan and the Community Mental Health Framework for Adults and Older Adults. All Integrated Care Systems have started work to transform their community mental health pathways from 2021/22 in line with published guidance, and ensure the transformed models exist in all Primary Care Networks by 2023/24. These models will enable people with severe mental illness to have greater choice and control over their care, and support them to live well in their communities We know that delivery of our ambitions for mental health services depends on growth of the mental health workforce through education and training, recruitment and retention. As of June 2022 there were 133,573 full time equivalent people working directly on mental health, across NHS trusts and NHS foundation trusts. This is an increase of over 24,400 new staff since March 2016. More generally, we launched a 12-week public call for evidence on what can be done across government in the longer term to support mental health, wellbeing and suicide prevention. This closed on 7 July 2022. We received submissions from over 5,000 respondents representing a broad range of stakeholders from across England and we are currently considering these. I know this will reply will be of little consolation to Ms Jennings’ family, friends, and all who loved her; I nevertheless hope it assures you of our aims to improve access to mental health support, prevent people reaching a mental health crisis, and ultimately saving lives. Kinds regards, MARIA CAULFIELD MP
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