Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0130, written 7 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Mar 2024 |
|---|---|
| Reference | 2024-0130 |
| Deceased | Nicola Rayner |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Suicide (from 2015) |
| Organisation named | Norfolk and Suffolk 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: Rt Hon Victoria Atkins MP Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 16th June 2023 I commenced an investigation into the death of Nicola RAYNER The investigation concluded at the end of the inquest on 23rd February 2024. The conclusion of the inquest was that the death was the result of:- Suicide, resulting directly from a lack of Mental Health bed provision in Suffolk and nationally. The medical cause of death was confirmed as: 1a Traumatic asphyxia 1b Hanging 4 CIRCUMSTANCES OF THE DEATH Nicola Raynor was verified as deceased at 19:43 on 10th June 2023, at the Addenbrookes Hospital, Cambridge, Cambridgeshire On the 6th June 2023 Nicola had been found hanging services attended, and Nicola was taken to Addenbrookes Hospital where she subsequently passed away as the result of a hypoxic brain injury. The emergency Nicola had a history of poor mental health, and at the time of her death was under the care of the Mental Health Services. Prior to Nicola being found hanging on the 6th June 2023, she had earlier that day attended a consultation with a psychiatrist, who had wanted to admit Nicola to a Mental Health ward immediately, however no beds were available. Nicola had a few days earlier (on 29th May 2023), also been seen by a Mental Health Nurse at the local Accident and Emergency department, who had also wanted to immediately admit Nicola into hospital, but due to Bank Holiday pressures, again no bed had been available. At the time of her death Nicola had been placed on a waiting list to be admitted to hospital, but due to non-availability locally, or nationally, admission was not possible. Had a Mental Health bed been available on the 6th June 2023, Nicola’s death would not have occurred. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given 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 as follows. – Had an informal Mental Health bed been available on the 6th June 2023, and Nicola had been admitted as both she and her psychiatrist had wished, her death would not have occurred. I am therefore concerned in relation to the overall bed capacity for those patients like Nicola seeking informal inpatient admission. Nicola’s case is not an isolated one. Evidence was heard from the Norfolk and Suffolk Foundation Trust, that on the day of the inquest itself (23rd February 2024), the availability of bed provision for informal Mental Health patients had failed to improve at all. The court heard that on the 23rd February 2024, the Operational Pressure Escalation Level was at its highest level (Four Black) and that at time of Nicola’s inquest, in Suffolk alone, there were 20 patients on a list waiting for an informal inpatient Mental Health bed. The court heard, that just as on the 6th June 2023, there were no other available informal Mental Health beds anywhere else in the country. The facts of Nicola’s case mirror those of another tragic Suffolk case, for which I produced a Prevention of Future Death Report in October 2020. I am therefore concerned, that any measures that may have been taken in the intervening period since October 2020, have neither adequately, or effectively, addressed this clear and continuing local and national risk of future deaths occurring. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 2nd May 2024 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. 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. Nicola’s next of kin. 2. The Chief Executive Norfolk and Suffolk NHS Foundation Trust. I am 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Name: Nigel Parsley Date: 7th March 2024 Appointment: HM Senior Coroner Jurisdiction: Suffolk
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.
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health & Social Care 39 Victoria Street London SW1H 0EU Mr Nigel Parsley The Coroner’s Court and Offices Beacon House Whitehouse Road Ipswich IP1 5PB 16 May 2024 Dear Mr Parsley, Thank you for the Regulation 28 report to prevent future deaths dated 07/03/2024 about the death of Nicola Rayner. I am replying as Minister with responsibility for Mental Health and Women’s Health Strategy. Firstly, I would like to say how deeply saddened I was to read of the circumstances of Nicola Rayner’s death, and I offer my sincere condolences to her family and loved ones. I can only begin to imagine the effect that this will have had on her loved ones and, whilst I know that it will come as little comfort to them, I nevertheless hope they will accept my heartfelt condolences. The report raises concerns over the lack of bed capacity for patients like Nicola seeking informal inpatient admission and that for the individual trusts, any measures that may have been taken, have neither adequately, or effectively, addressed the continuing local and national risk of future deaths occurring. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission. NHSE have informed us that the number of mental health beds required to support a local population is dependent on both local mental health needs and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary. In some local areas there is a need for more beds, this is being addressed in part through investment in new units, however, this should be considered as part of whole system transformation approach. This is supported by the NHS Long Term Plan (LTP), which is seeing an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards and in order to deliver more timely access to local beds. To address the wider system issues that impact on health services, a further £1.6bn has been made available via the better care fund from 2023-25. This funding can be used to support mental health inpatient services as well as the wider system which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally. CQC continue to monitor the mental health sector and NSFT through their regulatory monitoring powers. The CQC will also continue to work with and monitor the trust on an ongoing basis and, if there are concerns about risk to patients, will not hesitate to take action. Access to mental health care and the quality of the care remain a key area of concern. I would like to assure you that we take these concerns very seriously. The Government remains concerned about the prevalence of suicide. The Government’s new suicide prevention strategy for England is a five-year strategy which sets out the Government’s ambition for suicide prevention, together with over 100 actions that we think will deliver this. It is a multi-sector and cross-government suicide strategy, with actions from a wide range of organisations that will be delivered over the next few years. The strategy is supported by a wide-range of activity the government is funding and that will support people’s mental health. Between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7bn (in cash terms). This is significantly above the £3.4bn cash terms growth ambition set out at the time of the Long Term Plan. As part of our plans to improve mental health facilities, we are investing over £400 million to eradicate dormitories and give patients the privacy of their own ensuite bedroom - over 600 beds have already been replaced across 34 sites (out of a total of around 1,400 beds across 50 sites). The Department is also committed to ensuring that significant progress is being made in Norfolk and Suffolk to ensure that mental health services are of the high standard that patients and their families should rightly expect. This is why I met and will continue to meet with a range of campaigners, local stakeholders, the Trust and delivery partners to discuss progress on the Trust’s improvement plan, improvements in mortality recording, and how we can better understand the number of deaths, as set out in the Grant Thornton report. Whilst some improvements have been made, as set out in the most recent Care Quality Commission inspection report, it is clear that vital improvements are needed to be made and embedded to address the very significant challenges that remain. The Trust must be transparent and engage closely with families and local stakeholders as it aims to continue to make progress with its partners in improving mental health support in the area. It is critically important that we learn from patient safety incidents, so that the NHS can improve the quality and safety of the services it delivers. An inquiry is only one, but it is not appropriate in all circumstances. There are a range of mechanisms that the government can deploy to achieve this learning. The Trust is in the national Recovery Support Programme, which means it is subject to the highest degree of national oversight in segment 4 of the NHS Oversight Framework. NHS England is providing the Trust with focused and integrated support, with a full-time improvement director in place, and representation in the trust’s governance meetings so it has full visibility of the latest data on the improvements needed. It will work closely with the trust and stakeholders to ensure that the recent progress made continues and is built on. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD MP
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