Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0464, written 25 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Sep 2023 |
|---|---|
| Reference | 2023-0464 |
| Deceased | Robert Leigh |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Suicide (from 2015) |
| Organisation named | Greater Manchester Mental Health 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 THIS REPORT IS BEING SENT TO: , Chief Executive, Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, M25 3BL. 1 CORONER I am Alan Peter Walsh, HM Area Coroner for the Coroner Area of Manchester West. 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 the 17th of February 2023 I commenced an Investigation into the death of Robert Leigh, 75 years, born 15th of July 1947. The Investigation concluded at the end of the Inquest on the 26th of July 2023. The Medical Cause of Death was: - la Hanging The Conclusion of the Investigation was Suicide. 4 CIRCUMSTANCES OF THE DEATH 1. Robert Leigh (hereinafter referred to as the "Deceased'') was found dead at his home address the 7th of February 2022, having suspended himself by a ligature attached to a loft beam in the roof space at the premises. on 2. The Deceased was first referred to the Mental Health Services in in October 2020 with a further referral on the 5th of January 2022, following a deliberate self-harm attempt. He was detained under Section 2 of the Mental Health Act 1983 on the 7th of January 2022, and he was discharged on the 16th of June 2022. He had been treated for depressed mood. 1 2 3. Following his discharge, the Deceased was visited regularly by his Community Psychiatric Nurse (hereinafter referred to as the "YL''), and he was able to build a therapeutic relationship with YL, who had been appointed his Care Coordinator. The Deceased and his Partner were able to share their concerns with YL and be supported by the Community Mental Health Team. 4. On the 25th of October 2022 the Deceased was visited by YL, who found the Deceased to be calm and pleasant in mood. The Deceased reported that he was settled in mood and denied any suicidal thoughts or plans. YL arranged to see the Deceased again on the 15th of November 2022. 5. At the time YL was visiting the Deceased every 2 weeks but YL was absent from work between the 10th of November 2022 and the 6th of February 2023 and YL had no contact with the Deceased after the 25th of October 2022. 6. The Deceased lacked a Care Coordinator from the 10th of November 2022 and had no contact with a Care Coordinator after the 25th of October 2022 until a new Care Coordinator was appointed in January 2023 leading to a visit on the 4th of January 2023. 7. During the period from the 25th of October 2022 to the 4th of January 2023 the Deceased had no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed. 8. Following the absence of YL, a Care Coordinator was not appointed for 2 months and there was no appointment of a Community Psychiatric Nurse to cover the planned 2 weekly visits to the Deceased, which the Deceased and his Partner had found beneficial to his settled mood. 9. Following the 4th of January 2023, the Deceased only had one further visit from a Community Psychiatric Nurse/Care Coordinator prior to his death and there had been no continuity of care after the 25th of October 2022. 10. The Deceased was found dead at his home address on the 7th of February 2022, having suspended himself by a ligature His death was verified by a Paramedic from the North West Ambulance Service a short time after he was found. 2 3 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. During the Inquest evidence was heard that: - i. ii. iii. iv. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long- term absences. 2. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews their procedures and policies to cover the absence of a Care Coordinator, both in relation to short term and long-term absences, and in relation to the appointment of an interim Care Coordinator. 3. I further request that the Trust reviews their procedures and policies in relation to the responsibility of a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments. 4. I further request that the Trust reviews the procedures and policies in relation to resilience plans to cover the absence of an appointed Care Coordinator. 3 4 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that 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 the 20th of November 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: - 1. , Son 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 Signed 25th September 2023 - - - - - - --- "'1- Professor Dr Alan P Walsh, HM Area Coroner, Manchester West 4
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.
Trust Management Offices
First Floor, The Curve
Bury New Road
Prestwich
Manchester
M25 3BL
PRIVATE AND CONFIDENTIAL
Professor Dr Alan Walsh
HM Area Coroner, Manchester West
HM Coroner Court, Paderborn House
Howell Croft North
Bolton
BL1 1QY
20th November 2023
Dear Mr Walsh
Re: Robert Leigh (deceased) Regulation 28 Preventing Future Deaths Response
Mr Walsh, thank you for highlighting your concerns during Mr Leigh’s Inquest which concluded
on 26th May 2023. On behalf of the Trust can I apologise that you have had to bring these
matters of concern to the Trust’s attention. On behalf of Greater Manchester Mental Health
NHS Trust, I would like to offer Mr Leigh’s family our sincere condolences at this difficult time.
During the Inquest evidence was heard that:
ii.
i. During the period from the 25th of October 2022 to the 4th of January 2023 there were
no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-
week planned visits did not take place, so that 4 or 5 visits were missed.
There was no appointment of an interim care Coordinator or a Community Psychiatric
Nurse to cover the 2 weekly planned appointments following the absence of YL.
There was no responsibility on a Duty officer to review planned appointments during
the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse
to attend any planned appointments.
There were no resilience plans In place to cover the absence of a Care Coordinator,
either In relation to short term or long-term absences.
iii.
iv.
Please see the Trust’s response in relation to the concerns you have raised, and the actions
taken by the Trust:
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL.
Page 1 of 3
1.
I request that the Greater Manchester Mental Health NHS Foundation Trust
reviews their procedures and policies to cover the absence of a care
Coordinator, both in relation to short term and long-term absences, and in
relation to the appointment of an interim Care Coordinator.
Following Mr Leigh’s inquest, the team has now implemented a handover sheet, which is
completed by the Care Coordinator prior to any planned absence, such as annual leave or a
planned medical intervention. This ensures the Care Coordinator has considered any follow
up for service users that is required during their period of absence and identifies who will carry
out any planned interventions such as administration of depot medications, undertaking face
to face visits, and making telephone contacts. If specific follow up is not required during the
period of planned absence, then the service user, and their families or carers will be provided
with the contact details for the team, should they require additional support. The Team
Manager or Senior Practitioner have oversight and hold responsibility to ensure any actions
required are undertaken by the team.
For unplanned absences such as sickness, it is expected that the Care Coordinator, at the
point of contacting the Team Manager or Senior Practitioner to advise of their absence, will
provide a detailed handover of any work that is required to be covered.
Where leave is short term, this discussion will involve the prioritising of those visits that are
booked in and providing an update of the service users recent mental state, what support
measures are in place and identifying those who require urgent follow up from the duty officer.
If the Care Coordinator is unable to provide an update for any reason, then the Team Manager
or Senior Practitioner will review the Care Coordinator’s caseload and devise a plan to ensure
no service users are left without support. Additional support, from other members of the team,
for all service users can be discussed in the three times per week Zoning meeting and
interventions and staff allocated from this meeting.
If a Care Coordinator’s absence is long term, then the Team Manager will review the case
load and consideration will be given to those individuals either being reallocated to a new Care
Coordinator or a clear plan in place for the duty officer to follow up. Where absence is expected
to last longer than 4 weeks, then caseload reallocation will be actioned, prioritising those
identified with complex needs or increased risk profiles.
2.
I further request that the Trust reviews their procedures and policies in relation
to the responsibility of a Duty officer to review planned appointments during the
absence of a Care Coordinator and to arrange for a Community Psychiatric
Nurse to attend any planned appointments.
As noted above, it is the Team Manager’s or Senior Practitioner responsibility to review
alongside the Care Coordinator when reporting their absence, where possible, and
collaboratively agreeing the course of action required. The duty officer will then, at the request
of the Team Manager or Senior Practitioner, contact the service user, either by telephone or
a face-to-face visit, as clinically indicated.
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL.
Page 2 of 3
3.
I further request that the Trust reviews the procedures and policies in relation to
resilience plans to cover the absence of an appointed Care Coordinator.
The Service Manager will ensure that the Older Adult Community Mental Health Team
Standard Operating Procedure is updated to reflect these changes by the end November
2023. The Operational Manager will undertake an audit in three months’ time to ensure the
process outlined in this response is embedded and being adhered to.
Mr Walsh, on behalf of the Trust can I thank you again for bringing these matters of concern
to the Trust’s attention. I hope this response demonstrates to you and Mr Leigh’s family that
GMMH have taken the concerns you have raised seriously. If you have any further questions
in relation to the Trust’s response, please do let me know.
Yours Sincerely,
Chief Medical Officer
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL.
Page 3 of 3
See every Prevention of Future Deaths report matching Greater Manchester Mental Health NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.