Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0493, written 30 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 | 30 Nov 2023 |
|---|---|
| Reference | 2023-0493 |
| Deceased | Donna Donnellan |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Other related deaths |
| Organisation named | Northern Care Alliance NHS Foundation Trust · Pennine Care 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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. CORONER Chief Executive Northern Care Alliance Chief Executive Pennine Care NHS Trust I am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 23rd January 2023, I commenced an investigation into the death of Donna Marie Donnellan. The investigation concluded on the 25th September 2023. The medical cause of death was confirmed as 1a) Sudden death on a background of malnutrition 2) Peripheral Neuropathy. I recorded a narrative conclusion that Donna died as a result of complications arising from malnutrition likely due to an atypical eating disorder which was undiagnosed at the time of death. 4 CIRCUMSTANCES OF DEATH The deceased, Donna, had a long standing history of disordered eating which was characterised by her restricting her diet to certain types of food. In January 2021 she attended North Manchester General Hospital with leg weakness and poor appetite. Donna was diagnosed with peripheral neuropathy and remained in hospital for several weeks before being discharged to an intermediate care unit until the 5th March 2021. As a result of her peripheral neuropathy her mobility declined and she required a zimmer frame and subsequently a wheelchair. It was identified that she required assistance with care including meal preparation. Whilst initially accepting help it was eventually declined and she became increasingly reliant on her family. By September 2022 the Donna's weight had reduced to 25kg with a BMI of 10 and she was admitted to Fairfield General hospital. She remained an inpatient from the 16th - 28th September 2022. During this admission her weight increased however insufficient consideration was given as to whether she had an atypical eating disorder. During this admission Donna was seen by the Mental Health Liaison Team who concluded that she did not fit the criteria for anorexia and did not appear to have an eating disorder in accordance with the MEED guidance. The court heard a medical doctor disagreed with this assessment and felt Donna did have an eating disorder. However due to a belief that the Mental Health Liaison Team were "specialists", this view was overruled. Donna should have been referred to the Willows Eating Disorder Service. In addition there should have been a timely referral to the community dieticians. On the 3rd October 2022 the deceased was re-admitted to Fairfield General Hospital with a history of not having eaten for three days, weight loss and chest pain. The medical notes from her previous admission were not available to the treating clinicians. MEED guidance was not followed and she was not seen by a dietician. She should not have been discharged home on the 6th October 2022. She was found deceased at her home address on the 10th October 2022. 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) There was a lack of understanding between the Acute Trust clinicians and the Mental Health Trust as to the role of the Mental Health Liaison Team. Clarity is required as to whether the MHL T when asked to review a patient by the acute clinicians are reviewing so as to (i) make a diagnosis of an eating disorder or (ii) assess and assist in the consideration as to whether the Mental Health Act can be used to treat someone if they are refusing treatment. 2) There was a lack of understanding as to the pathways available to the acute clinicians for making a referral / seeking advice from the Specialist Eating Disorder Service ie the Willows. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 25th 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- Family of Donna Donellan 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 from. 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 Date: 30 November 2023 Signed: / lf(.i,,6t.(\_ V ,.
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.
Chief Medical Officer Group Headquarters 3rd Floor Mayo Building Stott Lane Salford M6 8HD Ms J Kearsley His Majesty’s Senior Coroner HM Coroners Court Floors 2&3 Newgate House Rochdale OL16 1AT Friday 12 January 2024 Dear Ms Kearsley Re: Inquest into the death of Donna Marie Donnellan – Regulation 28 Report I write following receipt of your report to prevent future deaths and to hopefully assuage your concerns that prompted it. At the outset I would like to take this opportunity to offer my sincere condolences to Ms Donnellan’s family for their loss. As you acknowledged in your closing remarks at the hearing in October, the Trust has undertaken significant work alongside Pennine Care NHS FT (“PCFT”) regarding the management of adult patients with eating disorders/complex and disordered eating. Nevertheless, it is understandable that some of the evidence heard at the inquest aroused your concern that there remained some uncertainty between the two trusts as to a) their respective roles when managing a patient in this cohort; b) the appropriate pathway available in seeking advice from or referring to the specialist eating disorder service. I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts. It is hoped that the policy, in conjunction with this response will alleviate your concerns which I will address in turn below: A5 1. There was a lack of understanding between the Acute Trust clinicians and the Mental Health Trust as to the role of the Mental Health Liaison Team. Clarity is required as to whether the MHLT when asked to review a patient by the acute clinicians are reviewing so as to (i) make a diagnosis of an eating disorder or (ii) assess and assist in the consideration as to whether the Mental Health Act can be used to treat someone if they are refusing treatment. This policy includes definitive confirmation as to the roles and responsibilities of the Trust’s doctors, dieticians, nursing, safeguarding and executive teams (§A157-161) and the PCFT Mental Health Liaison Team (“MHLT”) working with them (§A158). As you will note, the policy provision confirms that the MHLT is not expected to make any diagnosis of an eating disorder, but its role is wider than expressed in your report and encompasses advice, assessment and support beyond (but inclusive of) the use of the Mental Health Act. Regardless of any further tweaks to the policy it is agreed between the Trust and PCFT that this expectation will remain extant within any final, ratified policy. 2. There was a lack of understanding as to the pathways available to the acute clinicians for making a referral/ seeking advice from the Specialist Eating Disorder Service i.e. the Willows Again, notwithstanding the accepted confusion as to this matter during the evidence, the policy is clear as to the pathways available to Trust clinicians in respect of seeking the input of the Community Eating Disorder team in the provision concerning referrals. A referral by the Trust clinical team to the Community Eating Disorders team is mandatory on the patient’s admission; this referral will be assessed by the Community Eating Disorders team which will act as a central point of coordination resulting in one (or a combination) of the following outcomes: support and advice; MDT attendance, assessment; admission to the unit (§A149-150). By way of further clarification of the MHLT’s role, the provision concerning referrals also requires a mandatory referral to MHLT at the point of admission and includes clarity that the MHLT in response to that referral will provide (amongst other actions) an initial assessment that is “not eating disorder specific” (§A149). As with the provision concerning roles and responsibilities, the policy effect concerning referrals will remain extant in the final, ratified policy. As stated at the outset of this response, I sincerely hope that its content will provide you with reassurance that alongside the significant good work undertaken by both Trusts, the Trust has worked quickly with PCFT to resolve any apparent confusion as to roles and available pathways as demonstrated in the evidence. Yours sincerely Chief Medical Officer - Northern Care Alliance A6
Corporate Services Trust Headquarters 225 Old Street Ashton Under Lyne Lancashire OL6 7SF 23 January 2024 Private & Confidential Ms Joanne Kearsley HM Senior Coroner HM Coroner’s Court Floors 2 & 3, Newgate House, Newgate Rochdale OL16 1AT Dear Ms Kearsley Ref: Inquest touching on the death of Ms Donna Marie Donnellan I write in response to your Regulation 28 report dated 30 November 2023, and in respect of the concerns you have highlighted after hearing evidence at the Inquest of Ms Donna Marie Donnellan on 25 September 2023. I was sorry to learn that following witness evidence, you had concerns which had not been addressed. These have been reviewed and I understand that you have also received a response from Northern Care Alliance NHS Foundation Trust as the second party who provided witness evidence at inquest and received your concerns. This response Matters of concern: 1) There was a lack of understanding between the Acute Trust clinicians and the Mental Health Trust as to the role of the Mental Health Liaison Team. Clarity is required as to whether the MHLT when asked to review a patient by the acute clinicians are reviewing so as to (i) make a diagnosis of an eating disorder or (ii) assess and assist in the consideration as to whether the Mental Health Act can be used to treat someone if they are refusing treatment. Teams at Pennine Care NHS Foundation Trust have worked closely with colleagues at the Northern Care Alliance NHS Foundation Trust to review policies and procedures following the Inquest, to add clarity regarding referral. We have agreed to jointly review the policy owned by Northern Care Alliance NHS Foundation Trust, Management of Medical Emergencies in Adult Patients with Eating Disorders, which provides clear guidance for staff working within the Accident and Emergency A3 Department where to refer for the assessment and consideration of the Mental Health Act, with instruction to make a referral specifically related to an eating disorder. As teams work in partnership to meet the needs of patients within the Accident and Emergency Department, the policy will be available to staff from both organisations. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding. 2) There was a lack of understanding as to the pathways available to the acute clinicians for making a referral I seeking advice from the Specialist Eating Disorder Service i.e., the Willows. A meeting was held following the conclusion of the inquest, with representation from both organisations to review the Policy mentioned in response to point 1. This is available to all staff which should reduce any lack of understanding of referral processes or pathways, to ensure staff working in the Accident and Emergency Department can refer to this as guidance. I am sorry that you had cause to raise concerns with us directly at the conclusion of Ms Donnellan’s inquest and I trust this response, along with that provided by colleagues at Northern Care Alliance NHS Foundation Trust assures you that we have taken your concerns seriously and have thoroughly reviewed the issues raised. Yours sincerely Executive Director of Quality, Nursing & Healthcare Professionals/Deputy CEO A4
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