Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0452, written 15 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 | 15 Nov 2023 |
|---|---|
| Reference | 2023-0452 |
| Deceased | Madeleine Savory |
| Coroner | Darren Stewart |
| Coroner area | Suffolk |
| Category | Child Death (from 2015) · Suicide (from 2015) · Mental Health related deaths |
| Organisation named | East Suffolk and North Essex 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Rt Hon Victoria ATKINS MP 2 , Chief Executive NHS England 1 CORONER I am Darren Stewart OBE, Area Coroner, for the coroner area of Suffolk. 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 12th August 2022 I commenced an investigation into the death of Madeleine Eve SAVORY. The investigation concluded at the end of the inquest on 7th August 2023. The inquest was heard without a Jury. Madeleine died of: 1a. Hypoxic Ischaemic Encephalopathy 1b. Asphyxiation by Hanging I returned the following narrative conclusion: Madeleine Savory died as a result of Suicide whilst suffering from the effects of a mental health illness. Madeleine’s death probably was more than minimally contributed to by the failure of East Suffolk and North Essex NHS Foundation Trust to implement relevant policies which specifically dealt with the management of children such as Madeleine. This led to; a. Staff on Bergholt Ward not having the necessary understanding of Madeleine’s risk and how to manage this. b. Ongoing failures to conduct risk assessments for Madeleine. During the time of Madeleine’s admission there were only three risk assessments conducted and these were conducted on an ad hoc basis. c. Ongoing failure to ensure relevant information about Madeleine’s level of risk and the management of this was communicated to all staff involved in Madeleine’s care. This included the recognition and communication of the fact that the bathroom posed a particular risk for Madeleine. There was a failure on the part of Northgate High School to effectively implement the safety plan for Madeleine which was designed to keep Madeleine safe during school hours. The result of this failure meant Madeleine was able to leave school undetected and engage in a self-harm act which resulted in their admission to hospital. This failure possibly more than minimally contributed to Madeleine’s death. The lack of resources available to enable the timely allocation to Madeleine of a Tier 4 bed in a paediatric mental health facility possibly more than minimally contributed to Madeleine’s death. Regulation 28 – After Inquest Document Template Updated 30/07/2021 4 CIRCUMSTANCES OF THE DEATH Madeleine Savory was 15 years old when they died. Although not formally diagnosed with a mental health illness, at the time of their death clinicians were considering a working diagnosis of mood disorder depression of a severe nature. Madeleine had a very significant history of periodic suicidal ideation and a history of self-harm, the risk of both becoming acute in early February 2022. Madeleine was known to the Child and Young Persons Mental Health Service and to the Paediatric Ward at Ipswich Hospital. All organisations concerned with Madeleine’s care had knowledge of their history of suicidal ideation. On the 3rd February 2022 Madeleine absconded undetected from their school and carried out an act of self-harm which resulted in their hospitalisation. They were subsequently identified as needing a Tier 4 Bed admission on a paediatric mental health ward. Measures were put in place for such a bed to be sourced. At the time of Madeleine’s death a bed was neither identified nor allocated to Madeleine. During Madeleines admission on Bergholt Ward at Ipswich Hospital they were assessed as being a high risk of self-harm. Their mood fluctuated and on occasions Madeleine presented with no indication of either suffering from low mood or suicidal ideation. Throughout this period of time Madeleine’s presentation was complex and reflected the working diagnosis of mood disorder depression of a severe nature. A risk assessment on the 12th February 2022 identified the need for additional measures in managing Madeleine’s risk which included mental health observations. These measures were ceased on or around the 14th February 2022. The rationale behind why these measures were ceased is unclear. On the 19th February 2022, during the evening Bergholt Ward shift, Madeleine appeared settled and an earlier episode of distress during the day seemed to have no further impact on them. At around 22:05 pm Madeleine made their way to the bathroom securing the door behind them. They were not observed by ward staff entering the bathroom and there was a period of up to ten minutes during which Madeleine’s precise whereabouts was unknown. At around 22:20 pm the evening shift Nurse-in-Charge on Bergholt Ward was informed that Madeleine had been in the bathroom for at least ten minutes and was concerned that this period of time was longer than expected. Measures taken to rouse Madeleine by knocking on the door or calling out to them produced no response. Staff subsequently entered the bathroom and found that Madeleine had ligatured themself. Resuscitation efforts resulted in a return of spontaneous circulation and Madeleine was transferred to the Intensive Treatment Unit at Ipswich Hospital. However, Madeleine had suffered a fatal hypoxic brain injury and they sadly passed away on the 26th February 2022. 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) During the course of the inquest the evidence revealed matters giving rise to concern. I heard further evidence from the Interested Persons’ at a separate hearing on 17th October 2023 in relation to these concerns. At this hearing I received evidence from both East Suffolk and North Essex NHS Foundation Trust and Northgate High School concerning the measures they had put in place to address the failures identified during the course of the Inquest. I was satisfied that these measures addressed the concerns in relation to each of these Interested Persons and which had arisen from the Inquest. Regulation 28 – After Inquest Document Template Updated 30/07/2021 I also received helpful evidence from the East of England Provider Collaborative concerning the measures which that organisation had undertaken in their area of responsibility to address my concern in relation to the availability and allocation of Tier 4 beds in a paediatric mental health facilities to children such as Madeleine. 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. The availability, nationally, of Tier 4 beds in paediatric mental health facilities to allow for the timely allocation to children in need of care in such facilities such as Madeleine Savory. 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 January 10, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Madeleine Eve SAVORY East Suffolk and North Essex NHS Foundation Trust (ESNEFT) Norfolk and Suffolk Foundation Trust (NSFT) Suffolk County Council (SCC) (Children’s Services and Madeleine Eve SAVORY’s School) East of England Provider Collaborative I have also sent it to (Legal rep. SCC) (Legal rep. NSFT) (Legal rep. ESNEFT) (Legal Rep. Family) (Legal rep. EofEPC) (Family Solicitor) 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 Dated: 15/11/2023 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Darren STEWART OBE HM Area Coroner for Suffolk 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 Darren Stewart OBE HM Coroner's Court Beacon House White House Road Ipswich IP1 5PB Dear Mr Stewart, Thank you for your Regulation 28 report to prevent future deaths dated 15 November 2023 about the death of Madeleine Eve Savory. 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 Madeleine’s death and I offer my sincere condolences to their 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 significant delay in responding to this matter. I note that you have received satisfactory evidence from East Suffolk and North Essex NHS Foundation Trust, the East of England Provider Collaborative and Northgate High School concerning the measures they have put in place to address the failures identified during the course of the Inquest. Your report raises concerns over the availability of Tier 4 beds in paediatric mental health facilities. I understand that NHS England has 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 improve availability of Tier 4 beds where these are needed. The Department is supportive of NHS England’s approach to reduce reliance on inpatient mental health beds for children with a severe mental illness by reviewing and re-designing the model of provision of NHS-funded inpatient treatment for children and young as part of its Quality Transformation Programme and moving towards a community-based provision of care, where children and young people are able to access appropriate support in a timely, effective, and patient-centred way, close to home and in the least restrictive environment, whilst improving access to high quality inpatient care where this is needed. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD
Darren Stewart OBE
Suffolk Coroner’s Counrt and Offices
Beacon House
Whitehouse Road
Ipswich
IP1 5PB
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
2nd February 2024
Re: Regulation 28 Report to Prevent Future Deaths – Madeleine Eve Savory
who died on 26 February 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15
November 2023 concerning the death of Madeleine Eve Savory on 26 February 2022.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Madeleine’s family and loved ones. NHS England
are keen to assure the family and the coroner that the concerns raised about
Madeleine’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 Madeleine’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.
Your Report raised the concern over the national availability of Tier 4 beds in mental
health paediatric facilities to allow for the timely allocation of such facilities to children
such as Madeleine.
Significant improvements are in the process of being implemented across the NHS
Children and Young People Mental Health (CYMPH) inpatient pathway.
Care being provided close to home has seen a reduction in the numbers of young
people placed inappropriately out of their local area. Natural clinical flows (NCF) aim
to ensure a young person is only placed away from their local area when it can provide
the right therapeutic outcome. For Children and Young People (CYP) it is important
that every step is taken to avoid this given the impact on families, carers, links to school
and social networks. In March 2022, there were 145 CYP outside of NCF and in March
2023 there were 128 CYP outside of NCF.
NHS England has sought to improve the availability of local inpatient (Tier 4) care for
children and young people through several actions:
• The introduction of NHS-Led Provider Collaboratives which are key enablers for
bringing the care of CYP closer to home.
•
Investing capital and revenue funding into localised inpatient (Tier 4) and
alternative to inpatient provision over a three-year period.
• The NHS Planning Guidance 2022/23 outlined the need for Lead Provider
Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision
of General Adolescent and Psychiatric Intensive care Units to meet the needs of
their local population.
• The CYPMH Clinical Reference Group has developed an inpatient strategy which
provides an evidence base to support services when considering their workforce
challenges and team composition. A new Youth Intensive Psychological
practitioner pilot (YIPP) is now entering its third year and in partnership with Exeter
University has established roles
to
complement the team. There has been a refresh of the Care (Education) and
Treatment Reviews (CETR/CTR) policy, and an escalation policy has been agreed
with all LPC’s and regional teams.
inpatient multi-disciplinary
teams
in
•
In addition to steps taken to localise care and reduce reliance on inpatient care,
we have seen the establishment of many intensive alternative to admission
models introduced by NHS-Led Provider Collaboratives and Integrated Care
Boards, which support CYP to be cared for in the least restrictive environment and
close to home. Examples include the establishment of day units, strengthened
intensive support and outreach teams, paediatric liaison and thresholds for
admission and gatekeeping improved to actively avoid admissions.
• The Children and Young People’s National Quality Improvement Taskforce
delivered improvements to mental health, learning disability and autism inpatient
services for children and young people with a wide range of initiatives that co-
designed and co-delivered 39 change projects across CYP inpatient services to
support local improvements.
•
In 2022, NHS England commissioned a review of the Children and Young People’s
inpatient model recognising the continued pathway pressures and quality and
safety challenges. The review included how our English model compares
internationally, the views of children, young people and their families and requests
from local teams to work together to improve the model of care. The findings of
the review will present a future vision for CYPMH inpatient care and will be
published in Quarter 2 of 2023/24. Support will then be provided to local systems
and provider collaboratives to plan a timeline for implementing the changes,
coupled with implementation support as requested.
• Children and young people’s mental health interventions can take place in many
contexts and will depend on the clinical needs of the child as to whether
interventions are delivered in the community, whilst the child is in a placement, or
in an inpatient setting. We are working with the Department of Health and Social
Care and the Department for Education to ensure that the needs of children in
different settings are met fairly and equitably.
• Our strategy is to reduce reliance on mental health inpatient beds and to have
fewer young people being detained under the Mental Health Act. To support this,
the model of inpatient care is being re-designed to enable the move to a more
community-based provision of care, where children and young people can access
appropriate mental health support in a timely, effective, and person-centred way,
at home or close to home and in the least restrictive environment.
• We also recognise that for some children and young people, admission to hospital
will not be the most appropriate way to meet their needs. This has been a focus
of the transformation of children and young people’s mental health and continues
to be a priority in the NHS Long Term Plan.
• We are developing a national admission protocol for children and young people
with multi-agency partners which specifically includes the role of the Approved
Mental Health Professional and the legal requirements of the Mental Health Act
process and whether it is clinically appropriate for the young person to be admitted
for assessment and treatment.
I would also like to provide further assurances on national NHS England 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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