Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0360, written 2 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Oct 2023 |
|---|---|
| Reference | 2023-0360 |
| Deceased | Paula Lenihan |
| Coroner | Susanna Rickard |
| Coroner area | Birmingham and Solihull |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Birmingham & Solihull Mental Health NHS Foundation Trust. CORONER I am Susanna Rickard, Assistant Coroner for Birmingham and Solihull. 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 16 May 2023 I commenced an investigation into the death of Paula LENIHAN. The investigation concluded at the end of the inquest. The conclusion of the inquest was: Natural causes, contributed to by misuse of prescribed and controlled drugs. CIRCUMSTANCES OF THE DEATH On 06/03/2023 Paula Lenihan was found deceased at her home address. She had a complex medical history with both physical and mental health problems. Post mortem results revealed she had died as the result of heart disease and that she had a combination of drugs in her system suggestive of excessive use, or overdose. Together these may have caused toxicity but none were at levels which individually would have caused fatality. It is not possible to ascertain her state of mind shortly prior to her death, but when seen by her GP on 01/03/2023 no particular concerns had been noted. Following a post mortem the medical cause of death was determined to be: 1a Ischaemic and hypertensive heart disease 1b 1c II Combined toxicity 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 evidence given on behalf of the Birmingham & Solihull Mental Health NHS Foundation Trust was that in addition to this present case, where the deceased's risk assessment was not updated between November 2021 and her death in March 2023 despite circumstances which I was told ought to have triggered an update, there were a further number of cases within the Trust in which Root Cause Analysis reports had been produced, where it had also been found that risk assessments were not being completed in line with expectations; further, that it was not clear why this was happening. 2. If risk assessments are not being properly completed or updated, then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk. The fact that risk-relevant information may be recorded in the body of clinical notes is not reassuring, because a risk assessment or risk summary ought to capture the most salient risk information so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure. 3. The evidence given to me was that a 'task and finish group' has been set up to address the issue, which expects to have concluded by early next year, i.e. 2024, and that this group will be addressing matters as they are found rather than waiting until the final stage of its existence early next year. The evidence was that this group is at an early stage, with meetings considering the terms of reference and also, recently, the most appropriate persons to contribute to the group. 4. In the circumstances I am concerned that currently there is an extant issue within the Trust about the completion of risk assessments being, on a number of occasions, unsatisfactory. The task and finish group is at an early stage and I do not know what it is going to do, or when. I therefore cannot be reassured that the issues around risk recording which that group is going to examine have, at this point in time, been addressed. It seems to me that they continue to exist, because there has been no evidence to tell me otherwise. 5. In my opinion action needs to be taken to prevent the occurrence or continuance of the issue within the trust around the insufficient recording or updating of risk assessments, or to eliminate or reduce the risk of death created by such circumstances. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 November 2023. I, the coroner, may extend the period. 7 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Paula 8 I have also sent it to the regional Medical Examiner, ICB, NHS England, CQC, 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. 2 October 2023 9 Signature: Susanna Rickard Assistant Coroner for Birmingham and Solihull
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.
- Paula LENIHAN (
)
Date:
21 November 2023
Ms Suzanna Rickard,
Assistant Coroner,
Birmingham and Solihull Areas,
BIRMINGHAM
B4 6BJ
Dear Ms Rickard,
RE: Prevention of Future Deaths Report Paula Lenihan (deceased)
Thank you for your Prevention of Future Death Report dated 2 October 2023. I am sorry that
you felt that this was a necessary requirement under your obligation under Chief Coroner’s
Guidance No.5 to issue the same.
I understand that a Coroner’s power to prepare a PFD report is set out in Paragraph 7(1) of
Schedule 5 of the Coroners Act 2009, which states:
“(1) Where—”
(a) a senior coroner has been conducting an investigation under this Part into a person's death,
(b) anything revealed by the investigation gives rise to a concern that circumstances creating
a risk of other deaths will occur, or will continue to exist, in the future, and
(c) in the coroner's opinion, action should be taken to prevent the occurrence or continuation
of such circumstances, or to eliminate or reduce the risk of death created by such
circumstances,
the coroner must report the matter to a person who the coroner believes may have power to
take such action.”
I understand that during evidence presented at the inquest you concluded that the failure to
update the risk assessment did not contribute to the death and accepted that the information
was recorded within the records for staff to access. Your report sets out your belief that the
risk assessment should be updated ‘so that a professional looking quickly can absorb it; this
is all the more important where professionals are under time pressure.’ This aspect of your
report is not based on evidence heard at the inquest and the Trust does not accept that failing
to update the Risk Assessment section of the medical notes, when the information is already
within the records, would result in death. Even in times of pressure, clinicians would review all
the necessary pertinent information prior to reviewing a patient. The Trust disputes that the
threshold for a Prevention of Future Deaths report was met in this particular inquest.
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I also understand that during the inquest you accepted that the Trust may not be able to do
any more than is already planned and may have to repeat the evidence heard at the inquest
to you in any response to a PFD Regulation 28 report. You added that your position on this
was based on recent training that you had been provided with. This position is contrary to
paragraph 4 the Chief Coroner’s Guidance which states that ‘Broadly speaking, PFDs should
be intended to improve public health, welfare and safety.’ In December 2022, Dillon v HM
Assistant Coroner for Rutland and North Leicestershire [2022] EWHC 3186 (KB) (Admin) the
High Court endorsed the Chief Coroner’s Guidance that PFDs should be meaningful and
designed to have practical effect. Given that you accepted that it was unlikely the Trust would
be able to provide any more information as it was already doing all it could, this does not
suggest that any further improvements could be made to ‘improve public health, welfare and
safety’ or have any ‘practical effect’.
Further, you set out in your report that the evidence you heard explained that ‘this group (the
Task and Finish group) will be addressing matters as they are found rather than waiting until
the final stage of its existence early next year.’ Again this offers assurances that the Trust
would be alive to any issues which would arise from the findings of the Task and Finish group
and would take action immediately. The Trust would be grateful to understand the details of
the training you referred to as it seems to contradict the Guidance set out by the Chief
Coroner in issuing PFD’s, where you accept that the Trust cannot add any more to the
evidence heard.
In response to your request for further action to be taken; I can provide you with the following
update on the actions the Trust have taken:
The Trust has worked closely with teams, supporting with protected dedicated time for staff to
update risk assessment documentation. A project Group has been set up to look at our risk
assessment process. This has already met 4 times in recent months and includes a review of
our medical out patient clinics and whether the current risk documentation process is fit for
purpose, for our care support patients who are reviewed in these clinics. The review of our
risk management policy is also complete and the revised policy will be ratified shortly. This
work is being led by our Deputy Medical Director for Quality and Safety .
Completion rates for risk assessment for CPA patients within our community services have
moved from 61.14% on 10th August 2023 to 98% on the 25th October 2023 and for care
support patients we have seen an increase from 46% to 76.68 %
To ensure we continue to support staff in maintaining these levels of completion we will be
monitoring via our monthly local CMHT clinical governance committee and trust wide
performance delivery group.
I hope that this offers you further reassurance that the Trust were acting on the actions set
out within the action plan, as explained in more detail during the course of the inquest. We
look forward to receiving information around the training you referred to.
Yours sincerely,
Chief Executive
BSMHFT
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