Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0225, written 26 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 | 26 Apr 2024 |
|---|---|
| Reference | 2024-0225 |
| Deceased | Charlie Millers |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Organisation named | Greater Manchester Mental Health 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 DEATH S
THIS REPORT IS BEING SENT TO:
1. Rt Hon Victoria Atkins, Department of Health And Social Care, 39 Victoria Street,
London, SW1 H 0EU
CORONER
I am Joanne Kearsley, Senior 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 the 17th December 2020, I commenced an investigation into the death of Charlie Millers. Charlie
died on the 7th December 2020. The investigation concluded on the 25th April 2024. The medical
cause of death was confirmed as 1 a) Hypoxic Brain Injury 2) ADHD, Emotionally Unstable
Personality Disorder, Mixed Conduct Disorder and Autism . A jury recorded a narrative conclusion.
4
CIRCUMSTANCES OF DEATH
On the 2nd December 2020 Charlie was detained under Section 2 Mental Health Act 1983 on
Junction 17 the Child Adolescent Mental Health unit at Prestwich Hospital. At 22:31 hours he was
found in his room having tied a ligature. He died 5 days later in Salford Royal Hospital.
This was Charlie's third inpatient admission since July 2020. During his most recent admission it
was accepted that his self harming behaviour had escalated in frequency and severity. It was
recognised by his clinical team that being an inpatient was not assisting Charlie.
Charlie had returned from home leave at 19:45 hours on the 2nd December, it was known and
recognised that return from home leave was a time when Charlie would ligature. Charlie was
therefore on 1:5 minute observations with increased 1-1 support if he required it.
At the time the Trust Observation Policy allowed two forms to be used in order to conduct 1:5
observations:
- One form ensured the staff member recorded details every 5 mins. None of these forms were
December for Charlie. Indeed for his entire three
2nd
completed on the evening of the
admissions, spanning almost three months, only one such form was located.
-
A second form meant staff only had to sign once at the end of the period of observations ie
hourly. ("Level 2 hourly form")
In addition there was a separate Level 3 Observation 1: 15 minute form which was completed for all
young persons who as a matter of routine were checked every 15 minutes.
The court heard evidence that at the commencement of each shift the nurse in charge allocated
staff members their roles for the shift. This would change hourly and should be detailed on the
allocation sheet.
In addition the court heard that the staff member completing 1:5 minute checks on a young person
would be different from the person completing the 1: 15 minute checks on all the young people.
On the 2nd December Staff the a/location sheet shows;
8-9pm - No-one allocated to Charlie's 1:5 obs. HB allocated to 1: 15 obs for everyone.
9-1 0pm Staff Member HB allocated to Charlie's 1:5 obs. D allocated to 1: 15 obs for everyone
10-11 pm Staff Member D (female) allocated to Charlie's 1:5 obs. M allocated to 1: 15 obs for
everyone.
Level 3 1:15 Form
Between 9pm - 9.45 D signs every 15 minutes to say 1: 15 obs completed on all yps
10pm -10.30 staff HO signs to say 1:15 obs completed on all yps.
Level 2 Hourly Form for Charlie's 1:5 observations
8-9pm signed by o-=-fftold the-coorr he -signed-·this-forrn al-8prn-but-had not-done the-observations,
the space was blank and he used more space for his entry at 9pm
9-1 0pm signed by D
10-11pm signed by HO (Charlie was found at 22:31 hours)
The evidence therefore suggests that if Charlie 's 1:5 observations were being undertaken from 9pm
onwards, they were being undertaken by the same member of staff who was undertaking 1: 15 minute
checks on the other young persons.
His final ligature was the fourth one Charlie had tied from returning back to the ward at 7.45pm.
Previous Observation Issues
Death of RT
In October 2020 another young person had died on a different ward at this site. During the course
of that Inquest it was found observations were not being conducted appropriately in that staff were
not completing observation checks. As a result, management were supposed to be auditing
observation documentation daily. Albeit it was acknowledged audits of paperwork would not
evidence if staff were falsifying the documentation ie competing the paperwork but not doing the
check. A regulation 28 report was issued following this Inquest.
Death of AS
In June 2021 another young person died on another ward in Junction 17. At the time this individual
was on 1:5 minute observations. A similar regulation 28 report was issued in respect of the 1:5
documentation and the evidence to the court at that stage was that there was no other 1 :5
observation record other than the Level 2 hourly form. The court was concerned as there was no
In light of the evidence in Charlie's case this appears
record to say 1:5 checks were done.
inaccurate. At this time the audit by senior managers, which had been put in place in October 2020
should have been ongoing
Investigations and Reviews
1. Greater Manchester Mental Health Trust Root Cause Serious Incident Reports. All three
deaths were reviewed internally by GMMH. In respect of the investigation into Charlie's death
the review was completed by clinical team members. Whilst some inhouse training is provided
as to how to conduct reviews, they are not trained investigators. The Inquest ascertained
that not all the staff who were on duty on the night Charlie ligatured were spoken to or asked
for statements. The findings of the investigation relied on the completed observation sheets
to reach a finding that i) Charlie's 1:5 observations were conducted (ii) that they were
conducted by the staff member who was already completing 1: 15 obs.
There was no
questioning as to the accuracy of this or how this was possible. Nor whether this was
in line with Trust policy, nor whether this was a safe practice for all the young persons
on the ward. It did not consider whether the senior manager audits were being
conducted.
2. Following the deaths of Charlie and the other young persons NHS England commissioned
an Independent desktop review of the three cases. This review had access to the Trust's
Root Cause Analysis Serious Investigation Reports and simply relied on their findings.
This review did not highlight any concerns .
3. Greater Manchester Police -
In January 2023 the Inquest into Charlie's death was
adjourned following identification of the 1 :5 observation sheet detailing an entry for every 5
minutes. GMP were asked to review this case to consider if there were potentially any
individual criminal offences or corporate offences. GMP reported that there was no evidence
of any criminal offences. At this time GMP were also considering wider issues relating to
concerns raised from the BBC Panorama programme about the Edenfield unit which is based
on this site. GMP also investigated the other two deaths.
Not all the members of staff who were on duty that night were spoken to. Three members of
staff were interviewed. D and HO confirmed they were doing the 5 minute observations as
they signed the hourly sheet. This investigation does not appeared to have considered how
this was possible if the staff were conducting 1:15 checks on the other young people. Nor
whether this was in line with Trust policies or whether it made for a safe environment for all
the young persons.
4.
Independent Review of Greater Manchester Mental Health NHS Foundation Trust
December 2023 by Professor Oliver Shanley. This report was commissioned by NHS
England following the BBC programme which aired in September 2022.
gave evidence to the court in Charlie's Inquest. He told the court that as part of his
investigation in September 2023 his team requested copies of the audits of observations by
sen ior managers. He requested them from June, July and August 2023. He was subsequently
advised that it had been discovered by the Trust that there, "was no formal system and
process in the form of governance and the application of this audit was at ward level. "
Evidence showed in July 2021 the audit was completed 17 times out of 28 (61 %0. In 2022 it
was completed 25 times out of 52 (48%) and in 2023 it was completed 9 times out of 36
(25% ). In conclusion Professor Shanley found (para 9.103 ):
"The Trust reviewed and ratified their Therapeutic Engagement and Observation Policy in September
2023. However, it is noteworthy that it doesn 't address the original problem. There was no issue with
the policy and the Trust was able to demonstrate that a number of staff working on that ward
understood the policy and its implementation, but for reasons that are stiff not fully understood, they
failed to follow its guidance ."
5. No investigation was conducted.by the Care Quality Commission who were aware of Charlie's
death.
6. No investigation was conducted by the Health Services Investigations Body and it does not
appear they were made aware of this case . Without oversight of all cases and issues it is not
clear whether the report of Charlie's death in isolation would meet their criteria.
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. Deaths of patients detained under the Mental Health Act 1983 are not subject to any
independent investigation in the same way as deaths in police custody (Independent Office
Police Complaints) or in Prison (Prison and Probation Ombudsman). As a result,
investigations are not effective, no single body has oversight of previous concerns and how
these were going to be rectified by the organisation. Therefore critical learning and evidence
is being lost which may prevent future deaths.
2.
In addition the Investigations which are currently being undertaken are ineffective either due
to a lack of trained, investigators who conduct internal reviews or a lack of understanding of
complex health processes and procedures.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe each of you
respectively 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 24th
June 2024. 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.
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 Charlie Millers
Greater Manchester Mental Health Trust
NHS England
Care Quality Commission
Trafford Children's Services
Trafford Community CAMHS Service
-
-
As they are referenced in this Regulation 28 PFD
Manchester Police and the Health Services Safety Investigations Body
I have also forwarded the same to Greater
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.
9
Date: 26th April 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.
From Maria Caulfield Parliamentary Under Secretary of State for Mental Health and Women’s Health Strategy 39 Victoria Street London SW1H 0EU Joanne Kearsley Senior Coroner, Manchester North The Coroner’s Office 2nd and 3rd Floor Newgate House Newgate Rochdale OL16 1AT Dear Joanne, 21 June 2024 Thank you for your Regulation 28 report to prevent future deaths dated 26 April 2024, about the death of Charlie Millers. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Charlie’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Your report raises concerns over the way in which deaths of people detained under the Mental Health Act 1983 are investigated. In preparing this response, departmental officials have made enquiries with NHS England and the Care Quality Commission. All healthcare providers must notify the Care Quality Commission (CQC) when a person has died while being detained (or liable to be detained) under the Act. In addition, NHS England must notify the Department of the death of a child or young person in inpatient children and adolescent mental health service settings. This includes those detained under the Act and those in the care of a mental health setting as a voluntary patient. When the Department is informed by NHS England of any such death, the Department immediately notifies the CQC , which reviews the information and determines its regulatory response. It also notifies the National Confidential Inquiry into Suicide and Safety in Mental Health, which records all cases of inpatient deaths amongst adults and children and young people and routinely analyses them to establish the position nationally and make recommendations on what needs to be done to prevent further deaths. 1 Following Charlie’s death, CQC carried out a full review of his death and did not identify any provider failings under which to pursue a criminal prosecution. Whilst it is the case that there is no requirement for an independent investigation to be held into deaths of people detained under the Mental Health Act, the guidance relevant at the date of Charlie’s death - the NHS Serious Incident Framework March 2015 (Appendix 3) - was clear in advising that an Independent Investigation should be considered in the case of: “Deaths (and near deaths resulting in severe harm) of those detained under the Mental Health Act (1983) and, in certain circumstances, the deaths of informal psychiatric in-patients where; - the cause of death is unknown; and/or - where there is reason to believe the death may have been avoidable or unexpected i.e. not caused by the natural course of the patient’s illness or underlying medical condition when this is managed in line with best practice. This includes suicide and self inflicted death (NB: this also includes the death of recently transferred prisoners. Healthcare providers must inform the relevant prison service if there is reason to suggest that the care they received in prison could have contributed towards their death.)” The full guidance is available at: https://www.england.nhs.uk/wp- content/uploads/2020/08/serious-incidnt-framwrk.pdf NHS England has recognised that the Serious Incident Framework required improvements in relation to learning from incidents. The introduction of the Patient Safety Incidence Response Framework in 2022 represents a significant shift in the way the NHS responds to patient safety incidents increasing the focus on how incidents happen and the factors that contribute for the purpose of learning and improving patient safety. It is the responsibility of providers to ensure their organisation meets national patient safety incident response standards, to ensure the Framework is central to overarching safety governance arrangements and quality assure learning response outputs. From April 2024 it became a contractual requirement under the NHS Standard Contract for providers, including mental health providers, to implement the Patient Safety Incident Response Framework, which can be found at: https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-5.-Patient-Safety- Incident-Response-standards-v1-FINAL.pdf) The Serious Incident Framework makes clear that investigations need to be undertaken by appropriately trained and resourced staff and/or investigation teams that are sufficiently removed from the incident to be able to provide an objective view. In relation to Charlie’s death, Greater Manchester Mental Health NHS Foundation Trust undertook a Root Cause Analysis investigation in line with the NHS Serious Incident Framework process to mitigate against further reoccurrence and share identified learning. This was led by an RCA-trained investigator, supported by two consultant psychiatrists. Subsequent to this investigation, the Trust (rather than NHS England as stated in your report) commissioned an independent review to investigate the deaths of Charlie and two other young people led by an external Consultant Psychiatrist. The purpose of this review was to identify themes, further learning, omissions and recommendations. The review was supported in principal by NHS England in its regulatory role. In addition, NHS England commissioned an Independent Review into the care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust following failings within the Trust’s services. NHS England asked Professor Oliver Shanley OBE to lead the Independent Review, as the Independent Chair. The review was commissioned with the aim of understand what had gone wrong in the organisation and to make recommendations to prevent reoccurrence, and to bring clarity and reassurance to patients, their families, and staff, as well as the broader public, in respect of the ongoing safety of services that the Trust delivers. As part of the review process the Independent Chair made contact with Charlie’s family, to understand their experiences of the care Charlie received. The Review’s report was published in January 2024 and is available at: https://www.england.nhs.uk/north-west/our-work/publications/ind-investigation- reports/independent-review-gmmh-nhs-ft/ Since 2017, Trusts have been required to implement NHS England’s National Guidance on Learning from Deaths - A Framework for NHS Trusts and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care The purpose of the guidance is to help standardise and improve the way acute, mental health and community NHS Trusts identify, report, review, investigate and learn from deaths and engage with bereaved families and carers in this process. This guidance includes the governance process Trusts should follow, including case record review and investigation following recognised methodology. Trusts are required to collect and publish on a quarterly basis specified information on deaths, through a paper and an agenda item to a public Board meeting in each quarter. This data should include the total number of the Trust’s in-patient deaths (including Emergency Department deaths for acute Trusts) and those deaths that the Trust has subjected to case record review. Of those deaths subjected to review, Trusts need to provide estimates of how many were judged more likely than not to have been due to problems in care. Also published with the guidance is a suggested dashboard which provides a format for data publication by Trusts. This guidance is available at: https://www.england.nhs.uk/wp- content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf. NHS England has also shared details of the wider strategic interventions that it has put in place. Greater Manchester Mental Health NHS Foundation Trust is already receiving support to make improvements to the quality of its care as part of the NHS England Recovery Support Programme. The importance of rigour required when undertaking, recording, documenting, and auditing observations has been acknowledged and this forms a significant area of work as part of the Improvement Plan that has been put in place by the Trust and the oversight and monitoring of the Improvement Plan by NHS England’s System Improvement Board. As part of this improvement work, the Trust has appointed an Improvement Director to support this work. The Improvement Plan includes a workforce establishment review for nursing, based on the national Mental Health Optimal Staffing Tool (MHOST). This work is progressing, and the tool embraces all the principles that should be considered when evaluating/implementing decision support tools described in Safe, sustainable and productive staffing: An improvement resource for mental health first assessment and the results formed part of the enhanced recruitment plan for the Trust. Finally, a new statutory medical examiner system is being rolled out across England and Wales to provide independent scrutiny of deaths, and to give bereaved people a voice. From 9 September 2024 all deaths in any health setting that are not investigated by a coroner will be reviewed by NHS medical examiners. Medical examiners are senior medical doctors who are contracted for a number of sessions a week to provide independent scrutiny of the causes of death, outside their usual clinical duties. They are trained in the legal and clinical elements of death certification processes. The purpose of the medical examiner system is to: • provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths. • ensure the appropriate direction of deaths to the coroner. • provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased. improve the quality of death certification. improve the quality of mortality data. • • Medical examiners’ conclusions can inform learning to improve care for future patients, or, in a smaller number of cases, may be referred to others for further review. Their involvement also provides reassurance to the bereaved. They will provide independent scrutiny, taking a proportionate review of relevant medical records, interact with the doctor completing the Medical Certificate of Cause of Death and interact with the bereaved, providing an opportunity to ask questions and to raise concerns. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD
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