Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0510, written 7 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 | 7 Dec 2023 |
|---|---|
| Reference | 2023-0510 |
| Deceased | Katharine Fox |
| Coroner | Stephen Simblet |
| Coroner area | Essex |
| Category | Suicide (from 2015) |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: – CEO Essex Partnership University Trust The Lodge, Lodge Approach Wickford, Essex, SS11 7XX 1 CORONER I am Stephen Simblet KC, assistant coroner, for the coroner area of Essex. 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 26 October 2022 I commenced an investigation into the death of KATHARINE ANNE FOX, aged 51. The investigation concluded at the end of the inquest on 1st December 2023. The conclusion of the inquest was that the deceased had died from hanging, and the conclusion was suicide. 4 CIRCUMSTANCES OF THE DEATH Katharine Fox was being treated at home following a stay as an in-patient in Broomfield Hospital. Some of that stay had involved the deceased being detained under section 2 Mental Health Act 1983. While being treated in hospital, the deceased obtained psychology treatment in the form of a series of sessions with a trainee psychologist with whom she built a good clinical relationship and from which she reported benefiting significantly. Following her discharge from hospital, this psychology treatment effectively came to an end, since the procedures for receiving this treatment in the community were passed to an entirely separate set of clinicians. There was an entirely separate procedure for referral and provision of psychology sessions, with a very significant wait, and the deceased never in fact secured access to those services in the months between being discharged (in May 2022) and her death in October 2022. I was also told by the witness conducting EPUT’s own investigation that the teams use separate notes, and it may not always be possible for those notes to be accessed by other teams. This included evidence that a different computer system is used in the north of the county from in the south. 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 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] (1) I am concerned that the disconnection between the provision of psychology services to patients in hospital and the provision of similar psychology services to patients in the community, including the fact that the community psychology service does not receive any form of handover and that there is a substantial wait for the provision of psychology sessions which may well require continuity to be delivered effectively. (2) I am concerned about the fact, if that is indeed right, that some clinicians in the 1 psychology service may not be able to access notes made by clinicians in either other hospitals or other parts of the county. I was told that had the deceased actually managed to procure psychology sessions that the new psychologist may not have been able to read the notes of their predecessor if they were on a different computer system. 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 3rd February 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: (1) (2) EPUT - The Lodge, Lodge Approach, Wickford, Essex, SS11 7XX 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 7th December 2023 Stephen Simblet – Assistant Coroner 2
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.
Chief Executive Office The Lodge Lodge Approach Wickford Essex SS11 7XX 02 February 2024 Private and Confidential Mr Stephen Simblet Assistant Coroner for Essex Coroner’s Office Seax House Victoria Road South Chelmsford CM1 1QH Dear Mr Simblet, Ms Katharine Anne Fox I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 7th December 2023 in respect of the above, which was issued following the inquest into the death of Ms Fox. I would like to begin by extending my deepest condolences to Ms Fox’s family. The Trust sympathises with their sad loss. The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to these concerns in the hope that this provides both yourself and Ms Fox’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised. 1. Disconnection of psychology services to patients within the Hospital and the provision of such services to patients in the community. Within this concern you also raised your observations around handover between these two provisions as well as the wait times for psychology sessions. The Psychological Services Care Unit have been advised of this concern and have provided the following assurance. Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner. The Community Team psychological practitioner will discuss the care and treatment with the community mental health team to ensure the patient receives appropriate care and support in the community. The care in the community can be provided by the psychological practitioner or other appropriate team member under the supervision of a qualified registered psychological practitioner. The process of handover will be regularly audited to ensure that the care is safely transferred to the Community Team. Further, the Unit is currently reviewing the operational model to improve the transition and handover of care between inpatient and community psychological services, with the aim of streamlining this provision. The new process will include a joint consultation between the inpatient and community psychological services in order to aid care planning and formal handover of appropriate inpatient cases prior to discharge across each locality in Essex. Handover will be recorded on the patient’s electronic notes. Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process. In addition, for those patients who are considered to not require immediate or continuous psychological input, prioritisation will occur in accordance with their clinical need; all decision making will be recorded on the patient’s electronic medical record. Consultation between inpatient psychological services and Adult Community Psychological services will be undertaken as required. As stated above, all inpatient psychological services notes and reports are available on the electronic medical records system and reports are provided to care coordinators, again to facilitate joined up care. With regards to community wait times, the current demand for psychological treatments exceeds capacity; which is unfortunately not unusual within the NHS at this time. However, going forward the system of clinical prioritisation following case-specific discussion/handover will determine if urgency of need and risk warrants prioritisation. In relation to this, the Court is advised that in order to mitigate against any risk for those waiting for treatment in the community, the Psychological Services team implemented a new clinical process in 2023 which involves undertaking regular telephone contact with those waiting for psychological assessment and/or treatment. 2. Concerns relating to access to records made by clinicians This concern related to access by clinicians either in other hospitals or other parts of the county to relevant patient related records. The Court is respectfully advised that EPUT (like a number of NHS Trusts) uses multiple Electronic Medical Records Systems, which includes PARIS and MOBIUS. Staff within the Inpatient Psychological Services team have access to both systems, as well as Health Information Exchange (HIE) and can therefore access all records/reports. Our IT department has recently confirmed that all clinical staff in Adult Community Psychological Services can also access both systems. When a patient is transferred to the community the patient information can be accessed via the same systems and through HIE. The summary letter of the inpatient psychological care received by the patient is available on the system and also sent to the Care co-coordinator. The Care coordinator is also encouraged to request further information if necessary. In respect of the need to ensure all patient information is considered, Care coordinators are subject to regular supervision meetings in order to monitor any training needs and compliance with KPI’s in connection with safe patient care. The psychological practitioner (and other clinicians) will maintain clinical records in the electronic patient records, which are accessible to all team members. At the point of transfer of care or discharge, when the patient is being transferred to different team/locality (where a different electronic patient record is being used), a transfer summary will be provided to the team receiving the patient along with other care plan documents. As stated above, in addition, the teams will have access to records through HIE portal. Further, the Court is advised that it is commissioning a unified Electronic Medical Records System, in the interim Psychological Services will now have access to all of the required clinical systems and will also embed a new mechanism to ensure robust clinical information sharing between inpatient and community clinicians. This will be achieved through the aforementioned joint forum which will incorporate a formal handover of all required information. Should access to more detailed clinical information be required, this can be requested. I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care. Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above. We will await your direction before sharing a copy of this reply with the family. Yours sincerely Executive Chief Operating Officer / Deputy CEO
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