Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0377, written 9 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 | 9 Oct 2023 |
|---|---|
| Reference | 2023-0377 |
| Deceased | Mark McKessy |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The One Stockport Health and Care Board 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 24th February 2023 I commenced an investigation into the death of Mark Anthony McKessy. The investigation concluded on the11th July 2023 and the conclusion was one of Narrative: Died from the complications of decompensated alcoholic liver disease when agencies had not effectively shared information or recognised his needs until shortly before his death. The medical cause of death was 1a) Multi- Organ Failure; 1b) Pneumonia on a background of Decompensated Alcoholic Liver Disease; and II) Malnutrition. 4 CIRCUMSTANCES OF THE DEATH Mark Anthony McKessy had learning disabilities and care needs. He lived in the community. His regular and prolonged use of alcohol led to him developing alcoholic liver disease. He had limited capacity to understand the risks that this presented to him due to his learning disabilities. The significant threat his lifestyle and health issues posed to his life was not recognised by agencies. There was limited information sharing by agencies and no understanding of how his learning disability was impacting his health. As a consequence his health continued to deteriorate. He was admitted to Stepping Hill Hospital and was diagnosed with decompensated alcoholic liver disease. He deteriorated and died at Stepping Hill Hospital on 18th February 2023. 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. – The inquest heard evidence that he had significant leaning difficulties and his capacity was limited. He was known to agencies. Despite this the inquest heard evidence that steps to reduce the risks were not taken due to: 1. Poor communication/information sharing between agencies which meant that there was no coordination of care and no clear overview of his needs; and 2. A lack of recognition by agencies involved with him of his health issues and their inter relationship with his social care and learning disability needs including the extent to which he had capacity. This was compounded by limited Care Act assessments 1 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 4th December 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 namely 1) Council; and 3) Stockport NHS Foundation Trust , who may find it useful or of interest. on behalf of the Family; 2) Stockport Metropolitan Borough 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 Alison Mutch HM Senior Coroner 09.10.2023 2
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.
ONESTOCKPORT Health and Care Board Stockport Int egrated Care Partnership Private & Confidential Mrs Alison Mutch H M se·nior Coroner 1 Mottram Street Mount Tabor Stockport SKl 3AG Dear Mrs Mutch Mark Anthony McKessy (RIP) 11 December 2023 1. ~!::",'": 2023 HM CORONER MANCHESTER SOUTH I refer to the Regulation 28 Report issued following the inquest into the death of Mr McKessy and thank you for contacting the One Stockport Health & Care Board in regard to this matter. I am sorry to learn of the circumstances of Mr McKessy's death and would ask that you convey sincere condolences to his family. In your report you highlighted two key areas of concern, for which I w ill provide a response as follows:- A lack of recognition by agencies involved with him of his health issues and their inter relationship with his social care and learning disability needs including the extent to which he had capacity. This was compounded by limited Care Act assessments. Mr McKessy was registered at Cheadle Medical Practice who had regular contact with him . When he consulted with the practice he was a[ways supported by his parents. Records reflect that Mr McKessy received a Learning Disability Health Check on 24th January 2023 and fo llowing his health check he was seen by the Care Co-Ordinator. A role linked to the practice that provides specific support for patients with a learning disabi lity, he was also referred to the Enhanced Care Management Team. This team is within the practice, and is made up of senior clinicians and safeguarding staff. The role of the team is to review on a regular basis, complex cases to agree a way to best support the individual needs of the patient. Our enquiries into Mr Mckessy's support highlighted that whilst there is reference to Learning Disability Reviews and regular contact with Mr McKessy and his parents, the only forma l Learning Disability Health Check is the one in Jan 2023. We would expect further health checks for Mr McKessy. Supporting the completion of annual health checks for people with a learning disability with the health and socia l care needs is through a programme of work with Stockport Community Learning Disability Team . The team has a primary healthcare facilitator that works closely with GP's and other primary and secondary healthcare se rvices. They support the reviewing of the Learning Disability Registers held by the GP practices and . Part of Greater Manchester Integrated Care Partnership Stockport Health and Care Board Floor 1 Stopford House, Piccadilly, Stockport, SKl 3XE ONESTOCKPORT Health and Care Board Stockport Integrated Care Partnership provide training to the GPs in relation to best practice regarding the health promotion for people with a learning disability. This role has supported the uptake of the Learning Disability Annual Health Checks with a completion rate of 92.4% for 2022/2023 and a current rolling 12-month performance of 88.3%. The monitoring of the learning disability registers and ongoing support around annual health checks in the future will be undertaken by the new primary care assistant practitioners. Performance will be monitored in locality primary care teams to ensure quality and completion and is reported through to The Greater Manchester ICS. Recognising the challenge that some people with a learning disability face in accessing their GP, there is a Learning Disability Care-Coordinator in each Primary Care Network. This role further supports individuals with a learning disability accessing their GP and links to other appropriate services. The Primary Healthcare Facilitators meet regularly with the Care Coordinators to discuss individuals' circumstances and the service best to support them. The NHS provider, Pennine Care NHS Foundation Trust (PCFT) have recently appointed a team of five Primary Care Practitioners, one per borough; their role will be around supporting the offer and uptake of annual health checks (AHC) for people with a learning disability. The team are currently reviewing data to understand whether the registers include the right people who are eligible to receive AHC's and the offer and uptake of AHC's. They are looking at what the data tells us in relation to GP practices and numbers of service users but also demographics such as gender, age ,and ethnicity to identify where we may need to increase awareness and engagement with specific-groups and where we may need to prioritise support to practices where there may be lower uptake. PCFT aims to develop an understanding around the impact of this new role and gain feedback from service users and their carers and have developed a feedback questionnaire (which includes the Friends & Family Test) that will help in the development and adaptation of the offer in supporting service users. I hope this provides some reassurance to the work being undertaken by health in respect of people engaging with primary and secondary health services. We appreciate for Mr McKessy more could have been done with the further completion of annual health checks. In respect of Mr McKessy's contact with adult social care, I can confirm that in the two years prior to Mr McKessy's death, he received an annual Care Act review of his care and support needs. This included two assessments of his Care Act eligible needs; these took place in June 2021 and January 2022. Mr McKessy was living independently with the support from a strong family network and received low-level support from adult social care. This was primarily to access his local community for recreational purposes. Regrettably, the covid pandemic impacted on the delivery of this support and in turn on Mr McKessy's wellbeing. The two assessments completed focused on the presenting issues. At the time this was for Mr McKessy; securing support to manage his finances, maintain his flat and to access the community for shopping and recreational activities. Part of Greater Manchester Integrated Care Partnership Stockport Health and Care Board Floor 1 Stopford House, Piccadilly, Stockport, SKl 3XE ONESTOCKPORT Health and Care Board Stockport Integrated Care Partnership lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllli!IIIIIIZIYf21J We recognise there were missed opportunities at this time to fully understand his situation and the impact of drinking on his health and social care needs. We continue to improve front line practice to ensure our frontline teams increase their knowledge and confidence in completing holistic assessments. To ensure management oversite of individual assessments and reviews we are introducing peer discussions to strengthen social work practice. The social care and specialist learning disability health team are co-located to support a joined -up approach to interventions. This is further supported by managers across social care and health meeting on a weekly basis, using the forum to refer individuals for a multi-disciplinary and multi-agency approach. Following Mr McKessy's passing, analysis of our current offer, from both social care and health is being considered, including how we carry out assessments, provide advice, our signposting for individuals and our support provided people who experience any element of substance mis-use. This will be a standing agenda at the PCFT Quality Meetings; this will support consideration to further information or training for staff is required, whether we have appropriate information and resources to share with individuals and/or their carers. Regarding Mr McKessy's capacity to make decisions about his healthcare needs, this was regularly considered and assessed by his GP. Records reflect that on each occasion that capacity was cons'idered, he was found to have capacity to make decisions about his healthcare and any referrals made on his behalf. The last referral processed for Mr McKessy was to gastroenterology in October 2022. The option of a Power of Attorney (Health) was discussed and left as a matter for Mr McKessy's consideration. Poor communication/information sharing between agencies which meant that there was no co-ordination of care and no clear overview of his needs. Although there was activity at a GP practice level to share information and ensure escalations to any concerns were discussed. There were further opportunities to join up information to support a more holistic approach to Mr McKessy's support. All Stockport GPs use the Emis Clinical system, including our community and out of hours services. This means that community and out of hours services directly accessing individual patient clinical records. At the current time, Pennine Care NHS Foundation Trust cannot directly access a patient's full clinical history. I can confirm that there is ongoing work within Greater Manchester to extend sharing of information across healthcare services. To support further learning and the embedding of this learning from Mr McKessy's experience Stockport Safeguarding Partnership are linked with the LeDeR Review process. There will be a joint learning event in January 2024 in relation to Mr McKessy's life and death. All the agencies involved in supporting people with a learning disability in Stockport will be in attendance and agree a joint action plan to further strengthen information sharing and improvements to practice. We will also liaise with Mr McKessy's family, if they wish to be involved, to share their experiences of the health and social care Part of Greater Manchester Integrated Care Partnership Stockport Health and Care Board Floor 1 Stopford House, Piccadilly, Stockport, Sl<l 3XE ONESTOCKPORT Health and Care Board Stockport Integrated Care Partnership interventions. Once agreed; I would welcome sharing this with you w ith updates from actions to provide further assurances. I hope the above information is helpful to Mr McKessy's family. We continue to enhance the offer to people with a learning disability in Stockport and are committed to the development of accessible, person centred, co- ordinated care for people w ith a learning disability in Stockport and across Greater Manchester. · Yours sincerely Chief Executive and Place Based Lead ~ '· 1·, r 2023 HM CORONER MAN CHESTER SOUTH Part of Greater Manchester Integrated Care Partnership Stockport Health and Care Board Floor 1 Stopford House, Piccadilly, Stockport, SKl 3XE
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