Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0148, written 15 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 | 15 Mar 2024 |
|---|---|
| Reference | 2024-0148 |
| Deceased | Sarah Sutherland |
| Coroner | Karen Henderson |
| Coroner area | Surrey |
| Category | Suicide (from 2015) |
| Organisation named | Surrey and Borders Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Sarah Louise Sutherland A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: 1 Chief Executive, UK Council of Psychotherapy 2 President Royal College of Psychiatrists 3 Chief Executive NHS England 4 Chief Executive CQC 5 Brainwaves - 2 CORONER Dr Karen Henderson, H.M. Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 INVESTIGATION and INQUEST On 17th December 2023 I resumed an investigation into the death of Sarah Louise Sutherland. On 17th January 2024, the investigation was concluded: The medical cause of death given was: 1a. Suspension I recorded the following in Box 3 of the Record of Inquest: Sarah Louise Sutherland had significant mental health challenges with an ongoing history of suicidal ideation and self-harm. On the 17th December 2022, Ms Sutherland was found to have died by intention through self- suspension at her home address in Redhill having last been known to be alive on the 15th December 2022. I concluded Ms Sutherland died by way of Suicide. 5 CIRCUMSTANCES OF THE DEATH 1. In 2017 Ms Sutherland was referred to NHS Mental Health Services with suicidal ideation and depression and until her death remained under the care of the Community Mental Health Recovery Service and in times of crisis the Home Treatment Team with a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and Post Traumatic Stress Disorder. 2. At the same time, Ms Sutherland sought the assistance of a private psychotherapist providing ‘humanistic integrative’ therapy and had twice weekly appointments from September 2017 until 2 days before her death 3. The psychotherapist kept no clinical records of the initial assessment or treatment throughout the five years on the grounds that this was not necessary, and it would contravene GDPR regulations with no change of practice following Ms Sutherland’s death. 4. Throughout the five years as a client, Ms Sutherland’s psychotherapist could not provide any evidence of ongoing analysis, evaluation, assessment or review of Ms Sutherland as to whether this psychotherapeutic approach was beneficial. Nor was there any any consideration as to whether alternative psychotherapeutic approaches would have been more beneficial to manage Ms Sutherland’s mental health and other difficulties. 5. The psychotherapist was unable to adequately explain the benefit of ‘humanistic integrative’ psychotherapy for Ms Sutherland’s underlying mental health difficulties. 6. The psychotherapist did not undertake any risk assessments as to whether the psychotherapeutic approach was appropriate (e.g. exploring ‘trauma;’) given the underlying diagnosis of EUPD with the knowledge of a long history of suicidal ideation and acts of self-harm. 7. The psychotherapist did not provide evidence of an agreed and appropriate therapeutic boundary or to appear to respect one given that Ms Sutherland was given regular access to walking her dogs and to bring treats for her cat outside of therapeutic sessions, leading to a real concern that Ms Sutherland had become dependent on the psychotherapist outside of a therapeutic relationship. 8. Whilst there are sensitivities involved with ‘shared’ care between a private and NHS service there was no useful communication either formally or informally from either party to ensure both knew what each were doing to work in Ms Sutherland’s best interests with the psychotherapist being dismissive of so doing. 9. In the latter half of 2022 Ms Sutherland’s mental health deteriorated requiring intensive treatment from the Home Treatment Team. Although there was some stabilisation in her mental health with a reduction in negative thoughts, Ms Sutherland ended her life shortly thereafter. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph 1 have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise, you must explain why no action is proposed. 9 COPIES I have sent a copy of this report to the following: 1. See names in paragraph 1 above 2. 3. In addition to this report, 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 at the time of your response, about the release or the publication of your response by the Chief Coroner. 10 Signed: Dr Karen Henderson DATED this 15th March 2024
3 responses 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.
H.M. Coroners Office For the attention of: Dr Karen Henderson, Assistant Coroner Surrey Coroners Court HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA www.cqc.org.uk 22 April 2024 Dear Dr Henderson, Care Quality Commission: Response to prevention of future death report following an inquest into the death of Sarah Louise Sutherland Thank you for naming , Chief Executive of the Care Quality Commission (CQC) as a respondent in the Prevention of Future Death report issued following the death of Sarah Louise Sutherland on 17 December 2022. We note that the concern raised in the Prevention of Future Deaths Report at part 5 are as follows: 1) Guidelines for regulation and management of private psychotherapists. a) The psychotherapist did not fulfil the UKCP (of which she is a member) Code of Ethics and Professional Practice by failing to keep any clinical records in the care she provided to Ms Sutherland, nor has her practiced changed since Ms Sutherland’s death. b) The psychotherapist did not at any time undertake risk assessments and blurred if not crossed the boundary of a therapeutic relationship between a therapist and a client. Unfortunately, the CQC is unable to provide reassurance required regarding this concern or to comment upon it. The private practice where Sarah Louise Sutherland received psychotherapy is not registered with CQC and therefore not regulated by the CQC. The psychotherapist would not be required to register with CQC unless she was providing a regulated activity as defined in section 8 of the Health and Social Care Act 2008 and Part 1 paragraph 2 of the Health and Social 1 Care Act 2008 (Regulated Activities) Regulation 2014. There is no evidence at this time that suggests she was providing a regulated activity requiring registration and regulation by the CQC. appears to work alone as an ‘individual’ and offers a range of talking therapies for people with a range of mental health concerns. Searches of the following registers find no additional registration information to indicate Ms Woodhall is a health care professional as defined in the health and social care act and associated regulations https://www.cqc.org.uk/guidance- providers/regulations-enforcement/legislation • General medical Council • Nursing and midwifery Council • Health and care professions Council • Social Work England The regulated activity considered in this case is the treatment of disease, disorder or injury. The HSCA 2008 defines this regulated activity as follows: Treatment of a disease, disorder or injury covers a wide range of treatments. We don’t provide a complete list here, but it includes examples such as: • emergency treatment • ongoing treatment for long-term conditions • • giving vaccinations or immunisations • palliative care. treatment for a physical or mental health condition or learning disability This regulated activity applies to the treatment of disease, disorder, or injury in any setting, for example hospitals, clinics, hospices, ambulances, GP and dental surgeries, community services, and care homes. This activity covers a treatment that is: • provided by or under the supervision of a defined list of healthcare professionals (see what this means in our glossary of terms) or by a multi- disciplinary team that includes a listed healthcare professional, or • provided by or under the supervision of a social worker where the treatment is for a mental disorder, or by a multi-disciplinary team that includes a social worker where the treatment is for a mental disorder, and is • for a disease, disorder or injury. 2 It is acknowledged that the deceased was in receipt of therapeutic interventions in the community from registration, the treatment would need to be provided under the supervision of a listed healthcare professional. . However, in order to meet the scope of At this time, and based on the information available to us, there is no evidence that meets the definition of a healthcare professional, and therefore would not be required to register with CQC for the regulated activity treatment of disease, disorder or injury. We do not consider any of the other regulated activities appropriate in this case. We understand that is registered with UK Council of Psychotherapy. UKCP are better placed than CQC to act in the regulation and management of private psychotherapists. 2.) Proactive need for co-ordination of NHS mental Health services and Private Psychotherapy a) Following Ms Sutherland’s death, Surrey and Borders NHS Foundation Trust have, as long as client consent is obtained, introduced a ‘standard process for communication with private providers of psychological therapies’. However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients. CQC welcomes the action taken by Surrey and Borders Partnership NHS Foundation Trust to implement a process to standardise communication with private providers of psychological therapies. While CQC share the Coroner’s concerns in relation to the lack of a formalised mechanism for liaison and communication between NHS and private providers this is outside the scope of our regulatory powers. NHS England are better placed to act in setting requirements and expectations for improving this coordination of services. We appreciate the Coroner raising these concerns with CQC, since receiving the Regulation 28 report we have reviewed the information relating to the death in line with our regulatory process and methodology. Whilst we don’t consider there is any regulatory action that currently needs to be taken we will continue to monitor the trust and any new information that we receive in line with our internal process and methodology If you have any further queries, please do not hesitate to contact us further. 3 Yours sincerely Deputy Director South Network 4
Dr Karen Henderson
HM Assistant Coroner
Surrey Coroner’s Court
Station Approach
Woking
GU22 7AP
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
19 April 2024
Re: Regulation 28 Report to Prevent Future Deaths – Sarah Louise Sutherland
who died on 17th December 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15th
March 2024 concerning the death of Sarah Louise Sutherland on 17th December 2022.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Sarah’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Sarah’s care
have been listened to and reflected upon.
This response focuses on the areas of concern raised in your Report that are relevant
to NHS England national policy and programmes. We note that you have addressed
your Report to other organisations, such as the Care Quality Commission (CQC) and
the UK Council of Psychotherapy who will be better placed to respond to your first
concern around
for regulation and management of private
psychotherapists.
the guidelines
Your second concern raised the need for coordination of NHS mental health services
and private psychotherapy. The Summary Care Record (SCR) was originally designed
and communicated to support patients when they receive emergency care. Over time,
the significant value of access to SCR to wider healthcare services has been
recognised and, as a result, the SCR Team have worked with the Expert Advisory
Committee to extend its use into multiple other care settings through a governance
framework into which patients and professionals contribute.
The SCR Team at NHS England have done significant work with a number of private
sector organisations, including a range of private hospitals and privately funded
healthcare services trialling the use of SCRs within settings where they have
previously been unavailable. This work will continue throughout 2024. It is difficult to
define precisely what is included within private hospitals and privately funded
healthcare services. However, all private hospitals and independent healthcare
services that have approached NHS England to date seeking access to SCR have
either been onboarded into the existing proof of concepts or there have been
discussions with the requestors regarding initial setup and their use for access to SCR.
Learnings will be reported back to an Expert Advisory Committee to better understand
any benefits realised but also any potential unintended consequences.
The SCR Team will work with the Expert Advisory Committee to seek full rollout
approval within the independent/private sector and consider the scope of this approval
and any specific exclusions, constraints, or caveats. We already have full rollout
approval for Mental Health Services within the NHS, which would include
psychotherapists working within these services. However, we have not yet been
approached by organisations representing private psychotherapists.
Work is also in progress to review the interface between the NHS and non-NHS funded
independent health providers. This work is in its infancy, but NHS England can provide
an update to the coroner in due course. We understand that the CQC are also
undertaking work regarding standards for online care and exploring opportunities for
better sharing of information both into private sector providers and receiving
information back to the patient’s registered GP practice from private providers.
Surrey and Borders Partnership NHS Trust have developed guidelines to ensure all
staff are aware of their responsibility to work collaboratively and share information with
private providers. It is the responsibility of all providers and commissioners of health
and social care in England to share information, when it is likely to facilitate the
provision of health or social care to an individual and when it is in the individual’s best
interests, as set out in the Health and Social Care (Safety and Quality) Act 2015
(England).
The responsibility of professionals to communicate and share relevant clinical
information is also included in several professional regulatory body guidelines. The
Health and Care Professionals Council’s (HCPC) Standard of Conduct Performance
and Ethics 2.6 states that ‘You must share relevant information, where appropriate,
with colleagues involved in the care, treatment or other services provided to a service
user’. Additionally, the General Medical Council, Professional Standards of Doctors
(Domain 3 – Contributing to continuity of care) states ‘You must promptly share all
relevant information about patients (including any reasonable adjustments and
communication support preferences) with others involved in their care, within and
across teams, as required’.
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
Karen Henderson HM Assistant Coroner for West Sussex HM Coroner's Court Station Approach Woking Surrey GU22 7AP 2 May 2024 Dear Dr Henderson Response to Regulation 28 report to prevent future deaths This is the UKCP's response to your report dated 15 March 2024, made under paragraph 7(1) of Schedule 5 of the Coroners and Justice Act 2009 following the death of Sarah Louise Sutherland. As the Chief Executive of UKCP, I would like to express my deepest condolences to Sarah's family and friends. Thank you for your investigation and identification of the concerns in your report set out below. 1. Guidelines for regulation and management of private psychotherapists We thought it would be helpful if we set out our role and regulatory responsibility. We hold a national register of psychotherapists and psychotherapeutic counsellors. The main purpose of the UKCP Register is to protect the public, and to provide public confidence in the profession we regulate. Only therapists who meet our exacting standards and training requirements can be on our Register. Our Register is accredited by the Professional Standards Authority. We have a Complaints and Conduct Process (CCP) which provides a centralised and transparent process for considering complaints or concerns by members of the public and clients about therapists in relation to their clinical practice. We will investigate cases where there is evidence that calls into question a therapist's suitability to be on our Register and indicate a breach of UKCP's code of ethics and professional practice. UKCP regularly receives complaints about UKCP registrants from the NHS and third parties (non-clients) and these are processed under the CCP. We have not received a formal complaint about Sarah's private psychotherapist. Complaints must normally be made within 3 years of the conduct complained of. The time frame for considering a complaint under the CCP varies depending on the nature of the complaint, the documentary evidence and number of witnesses. Please note that if UKCP commences an investigation pursuant to the CCP about a registrant-the investigation is confidential. However, if there is an Interim Suspension Order imposed and/or the matter is referred to an independent Adjudication Panel - this will be published on the UKCP website, and the Adjudication Panel hearing is open to the public. UKCP will publish details of any complaint upheld on its website in accordance with the UKCP Publication of Decisions Policy. In view of the above, UKCP does not propose to take any action in relation to this concern. 2. Proactive need for co-ordination of NHS mental health services and Private Psychotherapy We note that Surrey and Borders NHS Foundation Trust have introduced a 'standard process for communication with private providers of psychological therapies' where client consent is obtained. We are working closely with the Professional Standards Authority and the NHS in discussing opportunities for collaboration in support of suicide prevention strategies. Yours sincerely, Chief Executive UKCP 2nd Floor. /\merica House T C20 7014 9955 F: 020 7014 9977 2 /\merica Square E: info@ukcp.org.uk London EC3N 2LU Registered Charity No. 1058545 Company No 3258939 Registered in England
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