Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0097, written 21 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Feb 2024 |
|---|---|
| Reference | 2024-0097 |
| Deceased | Oliver Beswetherick |
| Coroner | Julian Morris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Chief Executive of NHS England, Skipton House, London, SE1 6LH 1 CORONER I am Dr Julian Morris, senior coroner, for the coroner area of London Inner South. 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 27 November 2020 I commenced an investigation into the death of Mr Oliver Beswetherick, aged 24 years. The investigation concluded at the end of the inquest on 11 December 2023. The conclusion of the inquest was a narrative conclusion. 4 CIRCUMSTANCES OF THE DEATH Mr Beswetherick had suffered from depression and bulimia, since 2015 and 2018 respectively. During 2019 – 2020 he was seen regularly by a therapist and consultant psychiatrist, the latter confirming the diagnosis of bipolar affective disorder type II for which he prescribed medical treatment. Up until 22 August 2020, Mr Beswetherick was well. On 29 August he attended A&E and was seen by the psychiatric liaison nurse, who, after assessing him wrote to his consultant, whom he was due to see a couple of days later. That review took place on 31 August and the consultant immediately referred Mr Beswetherick back to his GP for urgent referral to the CMTH/ crisis teams. Mr Beswetherick and his partner sought updates from the practice over the following days, 1-3 September 2023. On 3 September, following further discussions about Mr Beswetherick’s suicidal nature, he was referred by his GP to the CMHT. Their assessment was that he should be seen face to face. However, Mr Beswetherick had moved out of the local catchment area (East London) to south of the river (Southwark). He was therefore advised to attend his local A&E to see the local psychiatric liaison nurse who would be able to 1 refer into the local services. No direct referral to the either the psychiatric liaison nurse or local services was made. On the morning of 4 September 2020, Mr Beswetherick was identified, having fallen from his flat to the ground. He was pronounced dead at the scene by LAS, the MPS deeming the scene non-suspicious. A note was found. 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) It became evidence during the inquest that CMHT/ Crisis teams do not have contact details of: (i) Psychiatric liaison nurse services in neighbouring (out of their locality) boroughs based in Accident & Emergency departments, or details of CMHT/ crisis teams in neighbouring boroughs. (ii) Such contact could provide for direct referral, contact and passing on of knowledge of cases between neighbouring organisations, especially when individuals have already been assessed and asked to attend for a face-to-face consultation. Otherwise, those individuals who seek help, may have to revisit the same process of being interviewed on multiple occasions with a sense of déjà vu and anxiety that they are not obtaining the urgent assistance and support that they require. That may lead to them not engaging when they had hitherto made every attempt to do so. To provide those contact details would seem a relatively simple task, so teams could contact each other, and the local psychiatric liaison nurses based within the A&Es. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 Wednesday April 17th. 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- NOK (Mother) for Medical Protection for East London NHS Foundation Trust for H Evans for SLAM 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 21.02.24 [SIGNED BY CORONER] Dr Julian Morris 3
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.
Dr Julian Morris
Inner South London Coroner District
1 Tennis Street
London
SE1 1YD
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
09 May 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Oliver Beswetherick who
died on 4 September 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21
February 2024 concerning the death of Oliver Beswetherick on 4 September 2020. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Oliver’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Oliver’s care
have been listened to and reflected upon.
Your Report raises the concern that Community Mental Health and Crisis Teams do
not have the contact details of Psychiatric Liaison, Community Mental Health, and
Crisis Teams within neighbouring boroughs.
All NHS services have access to the ‘Service Finder Tool’ which offers health and
social care professionals accurate and up to date information on available services
within a specific locality through a mobile-friendly interface that is quick and easy to
use. It is primarily aimed at healthcare professionals who already have a care pathway
in mind. Through NHS Service Finder, health and social care professionals can access
a variety of service information, including comprehensive contact details, eligibility
criteria, and referral instructions. Maps and directions to the services are also
available, and public service information can be emailed directly to a patient.
Additionally, the NHS website has a directory which indicates the nearest mental
health crisis line to a person’s postcode. This also allows clinicians to make the referral
to the appropriate service or direct the patient/clinician for next steps.
The NHS Long Term Plan (LTP) recognised the crucial role of community mental
health services and committed almost £1bn extra per year by 2023/24 to transform
and expand the provision of community mental health services for adults and older
adults with severe mental illness.
Since 2021, all areas have received significant additional funding to develop these
new integrated models of primary and community mental health services, based
around Primary Care Networks (PCNs). Services should adopt a ‘no wrong door’
approach to ensure people don’t get lost in the gaps between services. Services
should be easy to access, flexible, tailored to individuals whole-life needs and
delivered as close to home as possible. Continuing to expand and embed the
transformation of community mental health services remains a priority.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors, and
other clinical and quality colleagues from across the regions. This ensures that key
learnings and insights around preventable deaths are shared across the NHS at both
a national and regional level and helps us pay close attention to any emerging trends
that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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