Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0190, written 8 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Apr 2024 |
|---|---|
| Reference | 2024-0190 |
| Deceased | Carole Mather |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | Other related deaths |
| Organisation named | Northern Care Alliance 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt Honourable Victoria Atkins Secretary of State for Health and Social Care 1 CORONER I am Catherine McKenna, Area Coroner for the Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 13 January 2023 an investigation into the death of Carole Mather was commenced. The investigation concluded at the end of the inquest on 5 April 2024. I recorded a conclusion of Misadventure. 4 CIRCUMSTANCES OF DEATH The Deceased was 66 years old when her body was found in an alleyway next to her home address on 2 January 2023. A post-mortem examination established that she had died of hypothermia. The Deceased had a background of poor mental health and alcohol dependency. In December 2022, she experienced a downturn in mood and relapsed in her use of alcohol following an extended period of abstinence. She presented at Fairfield General Hospital on 1 January 2023 in an intoxicated state and complaining of shortness of breath. She discharged herself from hospital later that afternoon against medical advice which included the fact that she was placing herself at risk of death by declining hospital admission. The doctor who assessed her as having capacity to make the decision to discharge herself was not aware of her history of involvement with mental health services and did not consult with a senior colleague or obtain advice from on- call psychiatry as was required by the hospital protocol. The Deceased returned home directly from the hospital and was observed by neighbours to be in an intoxicated state on her arrival. Her body was found in an alleyway the following morning. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows:- The Court heard that the assessment of mental capacity in those with a chronic dependence on alcohol is often complex and challenging. This is particularly so when it involves a question around the individual’s ability to put their decision into effect (the concept of executive capacity). The decisions can often involve behaviours which give rise to a risk of the individual’s death. It was against this background that the Court heard of the lack of overarching guidance for health and social care practitioners which specifically addresses the application of legal frameworks available to manage and protect those with a chronic dependence on alcohol. Such guidance would be of benefit to health and social care practitioners and by extension to the individuals affected. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 31 May 2024. I, the Area 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 namely:- Family of the Deceased Northern Care Alliance NHS Foundation Trust Bury Safeguarding Partnership 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 from. 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. Date: 8 April 2024 Signed:
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.
Minister Whately,
Minister for Social Care
39 Victoria Street
Westminster
London
SW1H 0EU
Catherine McKenna
Area Coroner for the Coroner's Office of Manchester North
2nd and 3rd Floor, Newgate Office
Newgate
Rochdale, OL16 1AT
13 June 2024
Dear Catherine Mckenna,
Thank you for you coroner's report of 5th April 2024, to the Secretary of State for
Health and Social Care, Victoria Atkins about the death of Carole Ann Mather. I am
replying as Minister with responsibility for mental capacity policy.
Firstly, I would like to say how saddened I was to read of the circumstances of Mrs
Mather’s death, and I offer my sincere condolences to her family and loved ones.
Your report highlights concerns about the assessment of the mental capacity of
patients who have a chronic dependence on alcohol and how the decisions patients
make can involve behaviours that raises their risk of their death. Generally speaking,
if a person has mental capacity to make a decision to discharge themselves from
hospital, their decision must be respected.
If a patient was found to not have the mental capacity to discharge themselves, and
they are or will be deprived of their liberty, then the hospital may need to consider
whether to use the Deprivation of Liberty Safeguards (DoLS), under the Mental
Capacity Act 2005. The DoLS can authorise the deprivation of liberty of a person being
accommodated in a hospital or care home for the purpose of providing care or
treatment. Any such restrictions placed on a person in these circumstances must be
in their best interests and necessary and proportionate. Decision makers should
therefore make full consideration as to whether less restrictive options, such as
appropriate support packages, can be implemented in place of DoLS authorisation.
You also raised concerns about the lack of guidance that is available for health and
social care practitioners to address the application of legal frameworks to protect
patients with a chronic dependence on alcohol. All bodies with legal duties under the
MCA’s Deprivation of Liberty Safeguards must continue to operate these safeguards
to ensure the rights of people without the relevant mental capacity are protected.
Practitioners are required to stay up-to-date with the relevant case law.
Thank you for bringing these concerns to my attention.
Helen Whately
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