Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0155, written 20 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 | 20 Mar 2024 |
|---|---|
| Reference | 2024-0155 |
| Deceased | Jonathan Harris |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Jonathan Harris A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Chair NHS England PO Box 16738 Redditch B97 9PT 2 CORONER Miss Anna Crawford, 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 INQUEST An inquest into Mr Harris’s death was opened on 21 July 2022. The inquest was resumed and concluded on 4 March 2024. The medical cause of Mr Harris’s death was: 1a. Suspension 2. Paranoid Schizophrenia The inquest concluded as follows: Suicide. Jonathan Harris was 52 years old and had a diagnosis of Paranoid Schizophrenia. On 24 November 2021 he was discharged following a lengthy psychiatric inpatient stay to Hazel Lodge, which provides supported living accommodation in Camberley and is run by Comfort Care Services Ltd. At the time of his discharge from hospital Mr Harris was prescribed anti- psychotic medication in the form of a weekly depot injection of 600mg Zuclopentixol. Whilst he was living at Hazel Lodge Mr Harris came under the care of his local community mental health team, the Surrey Heath Community Mental Health Recovery Service, which is part of Surrey and Borders Partnership NHS Foundation Trust. In early February 2022, following a request by Mr Harris, the frequency of his anti-psychotic medication was suitably reduced to 600mg fortnightly as opposed to weekly. Thereafter in early May 2022, following another request by Mr Harris, his anti-psychotic medication was further reduced to 600mg every three weeks. The reduction in his medication in May 2022 was premature and was made without exploring signs that Mr Harris appeared suspicious when he was seen by the mental health team on 4 May 2022 and in circumstances in which Mr Harris was known to have a significant life change ahead, namely a house purchase and move, which would entail him moving to a new community mental health team. Thereafter, Mr Harris' mental health continued to deteriorate and on 24 June 2022 it was decided by the Community Mental Health Team that he required an assessment under the Mental Health Act. However, there was no inpatient bed available and therefore the assessment did not take place. Had the assessment taken place Mr Harris would have been detained under the Mental Health Act and admitted to hospital. In the early hours of the morning of 27 June 2022 Mr Harris deliberately suspended himself , resulting in his death. In doing so he acted with the intention of taking his own life, albeit whilst suffering from a relapse of his paranoid schizophrenia. Mr Harris would not have taken his own life had he remained well and the relapse of his Paranoid Schizophrenia materially contributed to his death. The relapse was precipitated by the initial reduction of his anti- psychotic medication in February 2022 and sped up and exacerbated by the further premature reduction in May 2022. Mr Harris would not have died had an inpatient psychiatric hospital bed been available on either 24, 25 or 26 June 2022. 5 CIRCUMSTANCES OF THE DEATH The circumstances of Mr Harris’s death are set out in the above narrative conclusion. 6 CORONER’S CONCERNS The MATTER OF CONCERN is: The court heard that a Consultant Psychiatrist post in the community mental health team that treated Mr Harris has been vacant with no suitable applicants since 1 May 2022. The court heard that this is in the context of a national shortage of suitably qualified psychiatrists. The court also heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds. The court is concerned that both of these matters present a risk of future deaths. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 8 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. Chief Coroner 2. Mr Harris’s family 3. Mr Harris’s executor 4. Surrey and Borders Partnership NHS Foundation Trust 5. Comfort Care Services Ltd 6. Surrey County Council 10 Signed: ANNA CRAWFORD Anna Crawford H.M Assistant Coroner for Surrey Dated this 20th day of March 2024
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.
Anna Crawford
Surrey HM Coroner’s Court
Station Approach
Woking
GU22 7AP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
9 May 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Jonathan Harris who died
on 27 June 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20
March 2024 concerning the death of Jonathan Harris on 27 June 2022 and directed to
the Chair of NHS England. I am responding on behalf of the organisation in my
capacity as National Medical Director but would like to assure you that the Chair has
also been sighted on and reviewed your Report and our response. In advance of
responding to the specific concerns raised in your Report, I would also like to express
my deep condolences to Jonathan’s family and loved ones. NHS England are keen to
assure the family and the coroner that the concerns raised about Jonathan’s care have
been listened to and reflected upon.
Your Report raises the concern that a Consultant Psychiatrist post in the Community
Mental Health Team treating Jonathan has been vacant for nearly two years and that
this was within the context of a national shortage of suitably qualified psychiatrists.
NHS England is working at a national level to deliver the Long Term Workforce Plan.
This is a robust and effective strategy to ensure we have the right number of people,
with the right skills and support in place to be able to deliver the kind of care people
need. It heralds the start of the biggest recruitment drive in health service history, but
also of an ongoing programme of strategic workforce planning. It includes ambitious
commitments to grow the workforce by significantly expanding domestic education,
training and recruitment, as well as actions aimed at improving culture, leadership and
wellbeing so that more staff are retained in NHS employment over the next 15 years.
The Plan includes a specific focus on the mental health workforce, including a
commitment to grow the number and proportion of NHS staff working in mental health,
primary and community care. The plan sets out an ambition to grow these roles by
73% by 2036/37. The Royal College of Psychiatrists is also actively engaged in
workforce planning and ensuring that there is a sustainable workforce of well-trained
psychiatrists.
These actions will aim to close anticipated staffing shortfalls in the NHS in the long
term, however Trusts have a responsibility to ensure safe staffing levels in the current
day to day operation of their hospitals. This is in line with Care Quality Commission
(CQC) Regulation 18 which states that providers must deploy enough suitably
qualified, competent and experienced staff to enable them to meet all other regulatory
requirements.
NHS England has engaged with Surrey and Borders Partnership Foundation Trust
(SABPT) on your concerns. We are advised that they are working to improve their
consultant recruitment rate and are making their recruitment offer more attractive by
offering recruitment bonuses, increasing junior doctor support and education and
leadership opportunities and introducing flexible working. We would refer you to the
Trust for further details on this.
Your Report also raises the concern that there is an ongoing shortage of available
psychiatric beds in Surrey, amidst a national shortage.
The number of mental health beds required to support a local population is dependent
on both local mental health need 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 where 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. A further £1.6bn has been
made available via the better care fund from 2023-25 which 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.
In 2024/25 NHS England and systems will have a renewed focus on improving patient
flow and reducing the use of out of area placements. This will be delivered through
ongoing improvements to community mental health services, as well as focussed work
to reduce inpatient lengths of stay and delays around discharge linked to onward care,
support and housing, all of which will improve access to mental health beds closer to
home for patients.
SABPT have a 6 bedded residence called The Retreat, which is hosted by an
independent organisation, Comfort Care. The service offers an alternative to in-patient
admission, providing non-clinical, therapeutic support in a less restrictive environment.
Their Home Treatment Teams oversee the referral process to this facility.
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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