Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0433, written 8 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Nov 2023 |
|---|---|
| Reference | 2023-0433 |
| Deceased | Leya Adris |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Alcohol, drugs medication related deaths, Care Home Health related deaths |
| Organisation named | Birmingham and Solihull Mental Health NHS Foundation Trust |
| 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 1 2 3 4 THIS REPORT IS BEING SENT TO: Birmingham and Solihull Mental Health NHS Foundation Trust (‘BSMHT’) and Birmingham and Solihull Intergrated Care System (‘ICS’) CORONER I am Emma Brown HM Area 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 5 June 2023 I commenced an investigation into the death of Leya Amra ADRIS. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Drug related CIRCUMSTANCES OF THE DEATH Miss Adris was pronounced deceased by paramedics at her sister's home, , Birmingham, at 09:07 on the 18th March 2023 after she was witnessed to suffer an episode of fitting. Post mortem testing has identified that her death was due to toxicity. Miss Adris had also taken excessive Both medications are used for the management of anxiety but were not prescribed to her and therefore she may not have known the appropriate doses. Miss. Adris had recently sought support for increased anxiety and suicidal thoughts but denied any immediate intent. She had spent a lot of time with family in the days before her death and had made detailed plans for the subsequent days. There was nothing to indicate that she was suicidal and is likely to have accidentally overdosed. Following a post mortem the medical cause of death was determined to be: 1a Acute fatal toxicity 1b 1c overdose II Mental Health issues 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. 5 The MATTERS OF CONCERN are as follows. – 1. On the 13th March 2023 Miss Adris had a telephone review with at The Park Medical Centre, who recorded that she had been taking had spoken to the primary mental health worker and had been referred to ‘Our roots’ for therapy and had an appointment. She also recorded: “states nothing seems to be helping her at present, states that she feels like things are worsening daily, states she has very poor concertation-cant watch TV and having to walk out at work as cant concentrate...she , GP for 2 weeks, has a history of severe mental illness-with her being under HTT and sectioned in 2019. Patient states she isnt as bad as she was then but her mood is getting worse. States she wants to go to sleep and not wake up asked if she has suicidal thoughts-states she has but wouldn't act on it right now-asked why states couldn't do it to her family. Advised therefore for referral to psychiatry.” 2. explained in her evidence that although she knew that Miss. Adris , on the 8th March and had had seen the primary mental health team nurse, another appointment arranged for the 30th March, she specifically wanted to make the referral to the community mental health team so that the opinion of a psychiatrist could be obtained if necessary. She said she felt this was warranted because of Miss. Adris’s history that she was getting worse daily and now couldn’t concentrate alongside her significant history. She filled out a BSMHT form entitled ‘Referral form for access to secondary mental health services’ which contained the record of the review and selected from the urgency options ‘Within 1 to 4 weeks of referral for all other referrals that do not fit within the above two categories [for assessment within 24 hours or symptoms of psychosis], but who require assessment and treatment by secondary mental health services.’ On the electronic submission she marked the referral as ‘urgent’ as the only options are ‘urgent’ or ‘routine’ and she didn’t feel this was routine. 3. That referral was received by the single point of access (‘SPOA’) but as Miss. Adris was under the care of the primary mental health team/neighbourhood team it was not sent to the community mental health team (‘CMHT’) but sent back to Mr. Agyepong at the primary mental health team. A statement from , Clinical Services Nurse Manager, Little Bromwich Centre, provided evidence that this is the system in operation for patients on the case list of the primary/neihbourhood mental health team. reviewed the referral on the 14th March and decided there was no need to bring Miss. Adris’s appointment forward or refer her to the CMHT as her thoughts were not active and there didn’t appear to him to have been a significant change. 4. said she and her colleagues at the practice were not aware that the referral would not be viewed by the CMHT (she also suspected this was the case for other GPs) and if she had known this she would have called up the CMHT directly because she specifically wanted a psychiatrist’s input. She said that if she’d wanted a further opinion from second opinion from the secondary care team. She also explained that if she had been made aware that the referral had been sent back to the primary mental health team and no action was being taken she would have contacted the CMHT directly to raise her concerns but she wasn’t informed of the outcome of the referral before Miss. Adris’s death. she would have contacted him directly. In essence she wanted a was aware that had seen the referral and was keeping his appointment on the 30th as he had made a record in the surgery’s records but she didn’t realise this was the end of the referral which she presumed would still be being dealt with by the CMHT. 5. When a GP has referred a patient for review and assessment by secondary services I am concerned that it is not safe that there is no consideration of that referral by secondary services and the GP’s opinion that secondary services need to be involved is unilaterally over-ruled. 6. I am equally concerned that not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected. 7. If there are grounds for a GP to believe review and assessment is necessary by secondary services, it creates a risk to life if that review does not take place. Whilst the evidence gives no reason to doubt the expertise and competence of primary care mental health practitioners the fact that they are not caring for patients with conditions requiring management by psychiatrists means that they will not have the same familiarity with such conditions and when psychiatrist input is required. In this case it was my conclusion that on the 14th March the primary mental health practitioner did underestimate the significance of the report of daily deterioration and a new difficulty concentrating for a patient with a history of serious mental illness that had required detention for treatment. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 January 2024. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: , next of kin. I have also sent it to the CQC and 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. 8 November 2023 Signature: Emma Brown Area Coroner for Birmingham and Solihull 6 7 8 9
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.
1st Floor Wesleyan Colmore Circus Birmingham B4 6AR Emma Brown – via email only Area Coroner for Birmingham and Solihull The Birmingham and Solihull Coroner’s Court Steelhouse Lane Birmingham B4 6BJ 12th January 2024 Dear Ms Brown, Re: Prevention of Future Death Report - [ ] I am writing in response to your Prevention of Future Death report dated 8th November 2023, in relation to the recent investigation into the circumstances surrounding the death of Leya Amra Adris. Firstly, may I apologise for the delay in our response and assure you that our organisation takes the findings seriously. We appreciate the thoroughness of your investigation and the comprehensive matters of concern outlined in your report. We are committed to working with partner to address these concerns and we note the response from Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) dated 15th December 2023. In particular, we will ensure that BSMHFT and General Practice have effective working relationships with clarity of referral processes between the two providers particularly with regards to the transformed Community Mental Health and Wellbeing Service and the associated referral form and processes. The interfaces between primary care and other providers is a particular focus for us and as a system we have several work programmes running in this space. Our new structures ensure that representatives of GP as a whole sector are included in key system work programmes, including Community Mental Health; this allows GP views to be heard and shape service change as well as to provide structured communication routes for escalating concerns and information about change. We also now have a central portal for General Practice which can contain all referral protocols in one place and will ensure that mental health ones are included within this. Yours sincerely, Chief Executive Officer Birmingham and Solihull Integrated Care Board
Legal Department Uffculme Centre 52 Queensbridge Road Moseley Birmingham B13 8QY Our ref: LeyaAdris Emma Brown – via email only Area Coroner for Birmingham and Solihull The Birmingham and Solihull Coroner’s Court Steelhouse Lane Birmingham B4 6BJ 15th December 2023 Dear Mrs Brown Re: Prevention of Future Deaths Leya Adris (deceased) Thank you for Prevention of Future Deaths letter of 8 November 2023. I am sorry that we did not have witnesses present at the inquest that would have been able to provide you with the assurances that you required at the time of the hearing. We have now liaised with the staff involved in order to be able to respond to your concerns in relation to the GP referral system to secondary mental health services and communication to GPs in respect of the same. Community Mental Health Services have been undergoing significant transformation since April 2021. In line with the attached national programme of work the government committed significant investment in Community Mental Health Services to integrate the ‘front door’ of Mental Health Services with Primary Care Networks (PCNs), improving access to services, providing a multi-agency approach and reducing unnecessary waits. There has been significant communication around the programme and the changes with our PCN Clinical Directors, leads and GPs. I attach documentation that has been shared via GP communication systems, which have been circulated in addition to many face to face and online engagement sessions that we have delivered such as: • Completed 1:2 Primary Care Network (PCN) engagement sessions as part of the ‘Additional Roles Reimbursement Scheme’ (ARRS) recruitment throughout 2021-2022 • PCN engagement session 25th May 2022 Customer Relations: Mon–Fri, 8am–6pm │ Tel: 0800 953 0045 │ Email: bsmhft.customerrelations@nhs.net │ Website: www.bsmhft.nhs.uk • Stakeholder engagement session 13th October 2022 (across all stakeholders including GPs) • GP Engagement Session 10th May 2023 • Ongoing meetings with GPs 1:1s and team meetings attendance (current) which have included: 1. Monthly GP access group led by the Integrated Care Board (ICB) 2. Community care collaboration group attended by lead GPs monthly 3. Number of local engagement sessions held face to face 4. Event led by BSMHFT Medical Director & the ICB face to face 5. Regular Communications via GP portal by the ICB Describing our newly transformed Community Mental Health and Wellbeing Service as ‘primary’ and ‘secondary’ services is not in line with the new model of care. The service in its entirety should be seen as ‘secondary care’ . For clarity, there are several functions within the transformed Community Mental Health and Wellbeing Service and service users accessing the service will be reviewed by experienced registered mental health practitioners and will then be directed to the most suitable part of the service dependant on their presenting need. This particular referral was managed by an experienced registered psychiatric nurse with secondary care expertise. Having reviewed the referral form there was no indication of a request specifically for a medical colleague review, neither was there an assessed need for medical input. Should the assessing psychiatric nurse have felt a medically trained colleague needed to review the patient, they would have bought the case to one of the regular Multi- Disciplinary Meetings (MDTs) or would have immediately spoken with a medically trained colleague for support. As stated, this was not indicated in this case. The referral was picked up and seen on the same day and given a follow up appointment was already in place this was reviewed and remained. This was well within the suggested time frames as indicated on the referral form. There was no mark on the referral form to suggest the referral was urgent. The Community Mental Health and Wellbeing Service is a non-urgent service, GPs are fully aware that urgent referrals that require urgent intervention should be referred to our Home Treatment Services, this referral was not marked as requiring such. All referrals coming into our Community Mental Health and Wellbeing Service, will be triaged locally, this has been the process in place for many years and is an already established process. BSMHFT central SPOA function is primarily an administrative function and referrals are sent by SPOA (Single Point of Access) to local services to triage (with the exception of older persons services). There appears to be some inaccuracies around the use of language, in that there is no such team as the ‘Primary Care Mental Health Team’ or ‘Primary Care Mental Health Workers’. We have one service as described (Community Mental Health and Wellbeing Service) that has a number of functions contained within it. We have worked with our GPs and on their advice renamed the front door function of our community mental health services as the ‘Neighbourhood mental health’ function. It is understandable that it can take time for new descriptors and models of care to be well understood and embedded. The assessment of mental health need should be retained within the specialist community mental health and wellbeing service and should not be for individual GPs to determine. As mentioned above PCNs now have access to experienced Mental Health professionals who are best placed to review need and determine where in the service individuals needs can be met. 2 If GP colleagues are unsure, concerned or want to raise a specific request about a patient, they should in the first instance discuss this with either local Mental Health clinicians that work with them in their surgeries or their neighbourhood mental health locality hub manager. They can also access the duty service or contact medical colleagues in the service directly. We have made alterations to our referral form for those GPs who continue to refer using the attached referral form. We have made it explicitly clear that the Community Mental Health and Wellbeing Service will review the referral and determine where the patients’ needs can be best met. We have also removed reference to referral to ‘secondary care services’ to avoid confusion. I appreciate that this evidence was not available at the time of inquest, and we hope that this will provide you with assurances that the system in place has been fully considered and is safe for patients. The referral form has been amended to provide more clarity and I hope that you have been assured that the system in place has been fully communicated to those GPs in the community. We will continue to share the message through the various forums that are in place to ensure that the message is shared fully to our partners in healthcare in GP practices. Yours sincerely Chief Executive 3
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