Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0496, written 4 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2023 |
|---|---|
| Reference | 2023-0496 |
| Deceased | Angela Collins |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Category | Alcohol, drug and medication related deaths · Suicide (from 2015) |
| Organisation named | East London 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Interim Chief Executive ELFT - 1 CORONER I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton Coroner Service 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 12 September 2022 I commenced an investigation into the death of Angela Dawn COLLINS aged 50. The investigation concluded at the end of the inquest on 30 November 2023. The Conclusion of the Inquest was a Narrative Conclusion: “The Deceased died from an overdose of prescription drugs taken whilst she was suffering from severe mental and emotional distress”. 4 CIRCUMSTANCES OF THE DEATH The Inquest found that: The Deceased had a history of depression which was made significantly worse by the death of one of her children in 2012. After taking a prescription drug overdose in February 2022, she came under the care of the Community Mental Health Team. After taking a further intentional prescription drug overdose on 3 May 2022, she was provided with a period of in- patient psychiatric treatment. Although she was discharged back to the Community Mental Health Team following her discharge, she did not attend her appointment with the Community Psychiatrist on 14 July 2022. By early August 2022, although it was clear that her mental health had deteriorated and that her relationship with her Community Mental Health Team Key Worker had broken down, she was not seen by any clinically qualified staff and had limited mental health support. A crisis point was reached when she awoke in the early hours of 18 August 2022 in distress and, after packing a bag which included half a week’s medication, left her home at 04.00 hours. Police subsequently attended her home and found a note suggesting a possible intention to harm herself. She was deemed to be a high-risk missing person and, after an effective search by police, she was located at the Travelodge in Toddington; although she denied being suicidal, police made further referrals to the Mental Health Team and Social/Children Services with concerns for her welfare. Although requested by Social/Children Services to see her, the Community Health Team did not go to see her but, instead, attempted to contact her by telephone. When the Deceased called them back at around 16.09 hours, her call was answered by administrative staff and, when she could not be put through to the clinically trained Duty Officer, she terminated the call. Although the Duty Officer called her back shortly after, she did not answer and no further action was taken. At around midnight, Travelodge staff found the Deceased slumped in the hallway outside her room. On informing them that she had depression, Covid 19, and had taken an overdose there was a 3 hour wait for an ambulance and, when the paramedics arrived at 03.43, they , they called an ambulance. Owing to service demand, Regulation 28 – After Inquest Document Template Updated 30/07/2021 found her in cardiac arrest on the bed in her room. Despite all resuscitation efforts, her death was confirmed at 04.29 hours. A bag containing multiple packs of medication was found under the bed and post- mortem examination confirmed that she had a blood level of as well as an excess of should die..” . A note found at the scene included the words “if I within the fatal range 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: Vulnerable adults at risk of accidental/intentional prescription drug overdose and potentially suffering a mental health crisis (such as Angie) appear to receive very limited or no support even though they are under the care of secondary mental health services provided by East London NHS Foundation Trust. 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 29, 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 Team Manger of Children Services, Central Bedfordshire Council – – Next of Kin I have also sent it to DDC of Bedfordshire Police – who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 9 Dated: 04/12/2023 Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Private & Confidential Ms Emma Whitting HM Senior Coroner Office of the Chief Medical Officer Trust Headquarters 5th Floor 9 Alie Street London E1 8DE 29 January 2024 Dear Madam RE: Regulation 28 Response – Angela Collins I am writing on behalf of East London NHS Foundation Trust (‘the Trust’) to provide a formal response to the Regulation 28 Report that you issued following the inquest touching the death of Ms Angela Collins. The Trust has carefully considered your Regulation 28 Report at the most senior clinical level. Following the tragic passing of Ms Collins, the Trust extends it most sincere condolences to the family and has very carefully considered your notice by extending a further review of all relevant circumstances surrounding this case. In your Notice, you wrote that “vulnerable adults at risk of accidental/intentional prescription drug overdose and potentially suffering a mental health crisis (such as Angie) appear to receive very limited or no support even though they are under the care of secondary mental health services provided by East London NHS Foundation Trust.” At the inquest, you heard evidence that although Ms Collins’ relationship with her Care Co-Ordinator had broken down, she was being supported by a different member of staff who was very experienced. The Trust’s original investigation sets out that Ms Collins was discussed by the Multi-Disciplinary Team (MDT) on the 10th and 17th of August. After Ms Collins left her home on 18th August and was subsequently seen by the Police, they communicated that they thought Ms Collins was at a ‘normal’ or medium level of risk, and that she had denied any thoughts of harming herself. Whilst evidence provided by the CMHT indicated that attempts were made to contact Ms Collins, albeit that there were documented difficulties in her engagement with the service, the Trust is now of the view that given Ms Collins complex family situation, her recent hospital admission due to a third attempt of suicide, the reports of concerns regarding a deterioration in her mental health, the fact she had not been seen by a qualified mental health professional since 14th July 2022, and her concerns relating to her being able to continue to see her children, which was noted as a protective factor, the CMHT should have considered undertaking a visit to Ms Collins, once it was established that she was staying at the hotel. Furthermore, the Trust is of the view that given the recorded difficulties between Ms Collins and her Care Coordinator and the situation that was unfolding, consideration of identifying an alternative practitioner from the team to visit her at the point she had been located at the hotel, would have provided an opportunity to assess the gravity of the situation first hand and make attempts in negotiating appropriate care and support to Ms Collins, at that time. In light of HM Coroner’s observations, the Trust has further reflected on the details of this case to see if there are actions that can be taken to further strengthen care in such circumstances. The Trust is now assessing the impact of the learning from this case and related previous cases to ensure that changes to practice are properly embedded and support is provided to staff on an ongoing basis. In doing so, the Trust believes vulnerable adults at risk of accidental/intentional prescription drug overdose and potentially suffering a mental health crisis (such as Ms Collins) will be supported appropriately. A detailed action plan is being developed with colleagues and will include items listed below. Please note that references to staff and managers are to CMHT staff in the Luton and Bedfordshire Directorate. 1. 2. A robust review of the Duty Function including how it is resourced, training requirements, practice standards, and senior oversight, across all Community Mental Health Teams in Bedfordshire and Luton. This work will commence in February 2024. Engage with administrative staff (who are usually the first people to talk to a service user and/or their carer) to clarify the purpose of their role in terms of supporting people over the phone who may be in distress and providing robust/timely support. This will include clarifying and getting their feedback on training needs and clear escalation pathways, plus ensuring that opportunities for reflection and de-briefs are made available. 3. Work with system partners to review the current ‘Multi-Agency Vulnerable Adult Return Home Interview Practice Guidance’ which was due to be reviewed by 06-Jul-2022. 4. 5. 6. 7. Ensure all staff attend the recently established ‘Think Family, Supporting people in complex family environments’ training. Establish a feedback mechanism that monitors the impact and success of putting learning into practice. Ensure that all managers are aware of and implement the People in Position of Trust (PIPOT) protocol which provides a framework to investigate allegations made by service users and ensures that both service users and staff are supported appropriately. This will also enable MDTs to consider appropriate and proportionate steps where a service user refuses to engage with their allocated worker thereby reviewing all the relevant facts of the case and mitigating against any potential increased risk to that person. Review the appropriate multi-agency protocol to ensure that staff are clear on the need for clear communication when supporting a person alongside other agencies and that roles and responsibilities are clearly articulated and where necessary reviewed to respond to ongoing and evolving circumstances. That records are both accurate, detailed, and timely and reflect the situation as it unfolds. That all teams provide clear routes of escalation to partner agencies if there is discourse or disagreement about how a case is being managed utilising the system-wide Cooperation between Teams protocol. The Trust prides itself on being a learning organisation that is constantly seeking to improve practice and the services it provides. In considering the Prevention of Future Deaths Notice and reflecting on the case again, the Trust feels assured of the learning that arises from this tragic event. Yours sincerely, Chief Medical Officer
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