Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0520, written 10 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 | 10 Dec 2023 |
|---|---|
| Reference | 2023-0520 |
| Deceased | Jessica Eastland-Seares |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Secretary of State for Health and Social Care 39 Victoria Street London SW1H 0EU 1 CORONER I am Penelope SCHOFIELD, Senior Coroner for the coroner area of West Sussex, Brighton and Hove 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 18 May 2022 I commenced an investigation into the death of Jessica Zoe EASTLAND- SEARES aged 19. The investigation concluded at the end of the inquest on 01 December 2023. The inquest was held with a Jury. The conclusion of the Jury was: “It is the conclusion of the Jury that systematic failures in Health and Social care led to a series of events, which caused the deceased periods of dysregulation culminating in regular bouts of self-harm, which ultimately ended in death by misadventure.” 4 CIRCUMSTANCES OF THE DEATH At 01.16 am on 17th May 2022 Jessie was pronounced deceased at Caburn ward, Millview Hosptial, Hove. East Sussex. She had been found with a ligature tied around their neck. Jessie had been diagnosed with Autistic spectrum disorder, ADHD, Complex traumatic stress disorder and emotional unstable personality disorder. Following a breakdown in the provision of her support package Jessie’s mental health deteriorated and was detained under Section 3 Mental Health Act 1983. She remained in Hospital from 4th March 2022 until the time of her death. 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: Sadly this case exposes the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to Regulation 28 – After Inquest Document Template Updated 30/07/2021 many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances. Despite a report from the Health and Social Care committee from 2021 this case showed that there does not seem to have been any real improvement and more lives are likely to be lost. Reading from this report, it says “The conclusion of this report was that Autistic people (and people with learning disabilities) have the right to live independent, free, and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so.” The report identified that “the community support and provision for autistic people (and those with learning difficulties) and financial investment in those services is significantly below the level required to meet the needs of those individuals and to provide adequate support for them in the community. “ The Inquest heard that two years on there still remains an acute shortage of provision. Evidence was heard that East Sussex Council had tried over 30 providers to help put in place support for Jessie but they could not find a placement for her so the only provision that they were able to offer her was supported housing with temporary care agency staff. This provision broke down which exsacerbated Jessie’s mental health. This then led to a Hosptial mental inpatient admisssion. 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 February 04, 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 Sussex Partnership NHS Trust East Sussex County Council Brighton and Hove City Council 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 10/12/2023 Penelope SCHOFIELD Senior Coroner for West Sussex, Brighton and Hove 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.
Penelope Schofield Senior Coroner West Sussex, Brighton and Hove From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health & Social Care 39 Victoria Street London SW1H 0EU 1 March 2024 Dear Penelope, Thank you for your letter of 10 December about the death of Jessica Zoe Eastland-Seares. I am replying as Minister with responsibility for Mental Health and Women’s Health. I was saddened to read of the circumstances of Jessica’s death and I offer my sincere condolences to Jessica’s family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. I am responding on the specific points you have raised in your report with regard to community provision for autistic people and levels of financial investment into these services. Under the Care Act (2014), local authorities have the duty to promote the efficient and effective operation of their care market, ensuring local care and support provision meets diverse local needs. They must have regard to current and future demand for care and support services and consider how providers will meet that demand. However, the Government recognises that shaping a care market is incredibly challenging. While local authorities are best placed to understand and plan for the care and support needs of their local population, there are elements of good market shaping practice that can be universally applied, such as involving those who draw upon care and their families in the commissioning process, supporting and investing in community services, and taking a prevention-based approach to shaping their market. That is why, in Next steps to put people at the heart of care, we committed to developing commissioning standards: to set clear expectations of what good commissioning looks like and to drive greater consistency across the country. We are also investing in a pilot training programme for senior local authority commissioners to help local areas with developing their skills in future-proofing their care markets and ensuring they have the data they need to shape their markets well. We want everyone who needs care in England to have outstanding quality care that empowers them to lead fulfilling lives and have the greatest possible independence. The social care workforce remains at the heart of our reform plans. We are supporting care workers to develop their skills and their careers, alongside a range of new funded training schemes. In December 2021, we set out our strategy for the social care workforce in our ‘People at The Heart of Care’ white paper and in 2023 we published ‘Next Steps to put People at the Heart of Care’ which set out more detail on the government’s plans for reform. It outlined our plans to invest in better workforce training, recognition, and career progression. The “Next Steps to put People at the Heart of Care” also set out how we are investing up to £700 million over this financial year and next, building on £100 million already invested in 2022/23, to improve the quality of social care provision and care outcomes. . The government has now made available up to £8.6 billion in additional funding over this financial year and next year to support adult social care and discharge. This includes £500m announced in January which has specifically been made available to support local authorities with the cost of social care in 2024/25. At the heart of this record multi-billion pound investment is our valued workforce. The Market Sustainability and Improvement Fund (MSIF) and the MSIF Workforce Fund, worth almost £2 billion over two years, are designed to support local authorities to increase adult social care workforce capacity and retention, reduce waiting times and increase fee rates paid to providers in their local areas. The MSIF Workforce Fund includes a particular focus on workforce pay. In addition, we are investing in recruitment and retention through better workforce training, recognition and career progression and on the 10th January 2024 the government announced: • The launch of the Care Workforce Pathway: For the first time, there will be a national career structure for the adult social care workforce, covering the breadth and complexity of care. • Over £50 million of funding for a new level 2 Care Certificate qualification: This will support up to 37,000 individuals in direct adult social care roles to enrol on the new qualification between June 2024 and March 2025. • An investment of over £20 million for apprenticeships: Local authorities and adult social care providers will be able to use the money towards training and supervising hundreds of new social work and nurse apprentices. • Subsidised training places: An uplift to the Workforce Development Fund that will expand access to learning and development, creating opportunities for the workforce to become experts in their field or progress into new roles. • A new digital leadership qualification: This will help equip social care leaders and managers with the confidence and capability to lead the implementation and use of technology in the delivery of care. This is in addition to the Government’s support to Local Authorities in addressing workforce pressures, including: • Launching the next phase of the Adult Social Care ‘Made with Care’ national recruitment campaign on the 9th October 2023. • Making care workers eligible for the Health and Care Worker Visa and adding them to the Shortage Occupation list (February 2022). • Providing £15m for the 2023/24 financial year to help local areas establish support arrangements for ethical international recruitment and bolster workforce in adult social care. We are determined to reduce the number of people with a learning disability and autistic people in mental health hospitals by supporting people to live well in their communities. The Building the Right Support Action Plan (published July 2022, alongside our response to the Health and Social Care Committee Report ‘The treatment of autistic people and people with learning disabilities’), brings together a wide range of actions we are taking across government and public services to help us drive progress on this. The cross- system Building the Right Support Delivery Board that I chair, monitors implementation of the commitments contained in the Action Plan. This financial year, we are investing an additional £121m to improve community support for autistic people and people with a learning disability, including funding for Children and Young People’s keyworkers. In addition, all Integrated Care Boards are expected to have an Executive Lead on learning disability and autism. This lead will support the board in planning to meet the needs of its local population of autistic people and people with a learning disability, and to have effective oversight of, and support improvements in, the quality of care for people in a mental health, learning disability and autism inpatient setting. Care (Education) and Treatment Reviews (C(E)TRs) and Dynamic Support Registers (DSRs) aim to prevent unnecessary hospital admissions for autistic people and people with a learning disability and to help ensure they get right support to stay well in their communities. NHS England has published refreshed guidance on Dynamic Support Registers (DSR) and Care (Education) Treatment Reviews which sets out expectations for Integrated Care Boards on which people with a learning disability and autistic people should be added to the local dynamic support register and about what actions should follow as a result of a person being on a register. We published our refreshed national autism strategy, on 21 July 2021. The strategy was backed by over £74 million in the first year to improve understanding in society, reduce diagnosis waiting times and improve access to high quality health and social care for autistic people (including funding to reduce numbers in mental health hospitals). The strategy was extended to children and young people, as well as adults, for the first time. This is in recognition of the importance of ensuring that autistic people receive the right support from early years and throughout their lives. The strategy also acknowledges the importance of autistic people being able to access community support, including social care, and that this should be available at the right time and tailored to their needs. We are currently prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people in line with the national Strategy. This will include setting out guidance on how local authorities can meet their responsibilities relating to social care provision for autistic adults. We expect to publish the updated draft Statutory Guidance for public consultation, this year. We recognise that the provision of timely community based mental health support tailored to an autistic person’s needs could reduce the risk of their symptoms deteriorating. Autistic children and adults should be able to access community-based mental health services that they require, just like everybody else. NHS England has published guidance for integrated care boards and other NHS organisations on meeting the needs of autistic adults in mental health services, which all mental health services should operate in line with. This guidance sets out nine recommendations that should be applied across all levels of general and specialist mental health provision – from services to support autistic people to stay well in the community; through to planned mental health care; crisis, intensive and unscheduled care; and inpatient mental health care. This guidance is intended to support improvements in the accessibility, acceptability, and effectiveness of mental health provision for autistic adults. I hope this response is helpful in setting out the actions being taken to improve community provision for the care and treatment of autistic. Thank you for bringing these concerns to my attention. Best Wishes, MARIA CAULFIELD
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