Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0232, written 30 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 | 30 Apr 2024 |
|---|---|
| Reference | 2024-0232 |
| Deceased | Mohamed Ellaboudy |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Railway related deaths · Mental Health related deaths |
| Organisation named | Berkshire Healthcare 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 DEATHS THIS REPORT IS BEING SENT TO: Chief Executive of Berkshire Healthcare NHS Foundation Trust 1 CORONER I am HEIDI J CONNOR, Senior Coroner for Berkshire for the coroner area of Berkshire 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. It is important to note the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London. This case clarifies that the issuing and receipt of a Regulation 28 report entails no more than the coroner bringing some information regarding a public safety concern to the attention of the recipient. The report is not punitive in nature and engages no civil or criminal right or obligation on the part of the recipient, other than the obligation to respond to the report in writing within 56 days. 3 INVESTIGATION I conducted an inquest into the death of Mohamed Ahmed Hany Ellaboudy (known to the family as Moh), which concluded on 24th of April 2024. I recorded a narrative conclusion as follows: Mohamed Ellaboudy died after placing himself in front of a moving train. His actions were deliberate, but his mental state and capacity to form intention are unclear. The family requested me to refer to the deceased Moh. I will reflect that in this report. 4 CIRCUMSTANCES OF THE DEATH Moh was a 34 year old man who had been diagnosed with paranoid schizophrenia. He had a significant mental health history, having been admitted to psychiatric hospitals in 2011, 2017 and 2020, before his final admission in 2022. He had also been an inpatient in psychiatric units abroad. There had been previous attempts by Moh to take his own life. Previous relapses in his mental health state had been associated with Moh declining to take his anti-psychotic medication. He was receiving Aripiprazole via depot injection. Moh stopped taking this medication again in December 2021, and he was detained under the Mental Health Act in July 2022, under Section 2 of the Mental Health Act 1983. Moh was discharged from Prospect Park Hospital, Reading Berkshire in August 2022. A discharge summary was sent to his GP practice at that time, but there was no further correspondence from the mental health trust to the GP until the end of March 2023. The inquest focused on the time from when Moh first stopped taking his anti-psychotic medication again (March 2023), to the time of his death (8th September 2023). During that time period, there were two telephone calls to his GP, and a telephone call with the practice mental health nurse. Regulation 28 – Before Inquest Document Template Updated 30/07/2020 Looking at the same period of time from the mental health team’s perspective, there were two appointments with a specialist doctor (both by telephone), and two brief telephone conversations with community mental health team nurses. By March 2023, the mental health teams knew that Moh was no longer complying with his medication. They knew his previous history of relapses when coming off medication. They knew that Moh was not working. These had been clearly described in a previous discharge summary as relapse signs for Moh. There was no face to face appointment to assess other potentially important risk factors, such as self neglect. We heard evidence that Moh himself insisted on not having face to face appointments as he feared being detained under the Mental Health Act again. I accepted evidence from the psychiatry witness that it is sometimes better to have at least some contact with a patient, rather than pressurising them and the patient refusing to have any contact at all. Whilst this may be true in practical terms, there was no documented rationale in this sense. It was accepted by the trust that there was a distinct lack of proactivity, rather than a conscious plan, particularly in the last months of Moh’s life. There were matters which troubled me about Moh’s case. He was unwell enough to be detained under the Mental Health Act in July 2022. By then he had had multiple previous relapses and admissions and attempts to end his own life. After being discharged from Prospect Park Hospital, he was under the auspices of a care co-ordinator, who largely spoke to him by telephone. It is very stark to note that the last face to face contact he had with any mental health professional (after being discharged from Prospect Park Hospital in August 2022) was February 2023, when he went for his last depot injection. He had no face to face appointment after that, and he died 7 months later. I was also concerned to note that the last multi-disciplinary team discussion about Moh was in May 2023. A later MDT would have been an opportunity for Moh’s case to be considered in terms of alternative contact methods and more comprehensive assessment of risk. The evidence showed that Moh had expressed a clear wish not to have face to face appointments for fear of being detained under the Mental Health Act again. A number of other relapse signs were also present and likely to be escalating in the final months of his life. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving 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 are as follows: 1. I am concerned about whether systems are in place for sufficiently robust care coordination for patients who have been discharged from a mental health setting, particularly in the context of detained/recently detained patients. 2. Reliance on telephone rather than face to face appointments. 3. Regularity / thresholds for MDT discussions. 4. Absence of a clear route for family to report concerns, even where a patient does not wish confidential information to be given to their family. 5. Policy / expectation for correspondence with primary care, particularly in the time after discharge from hospital. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE Regulation 28 – Before Inquest Document Template Updated 30/07/2020 You are under a duty to respond to this report within 56 days of the date of this report, namely by June 25, 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 Moh’s family. I have also sent this report to the following recipients, who have an interest in this matter: 1.Legal representative for Moh’s GP. 2.Legal representative for Berkshire Healthcare NHS Foundation Trust. who may find it useful or of interest. 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 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 coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 30/04/2024 HEIDI J CONNOR Senior Coroner for Berkshire for Berkshire Regulation 28 – Before Inquest Document Template Updated 30/07/2020
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.
Heidi Connor
Senior Coroner for Berkshire
Coroner’s Office
Reading Town Hall
Blagrave Street
Reading
RG1 1QH
18/06/2024
{17/06/1
Dear Madam
London House
London Road
Bracknell
Berkshire
RG12 2UT
Re: Inquest touching the death of Mohammed Ellaboudy
I write on behalf of Berkshire Healthcare NHS Foundation Trust ("Berkshire Healthcare") further to the
inquest of Mr Ellaboudy which took place on 24 April 2024 to provide a response to the concerns raised in
the Regulation 28 report dated 30 April 2024.
Care Coordination for recently discharged patients
Berkshire Healthcare are progressing changes to the way care is coordinated, planned, and delivered for
our mental health patients, treated in the community. We have commenced a programme of work to move
away from the Care Programme Approach (CPA). This is in line with guidance from NHS England and the
national Community Mental Health Framework (which has been coproduced with service users, carers
and professionals) and calls for providers to move away from care co-ordination as an intervention in itself
and focus on delivering compassionate, meaningful, intervention-based care which has been planned
between the service user and their care team. The roll out of this new model has commenced.
To support staff to deliver within the new model new five-day clinical skills training is now in place, that we
are progressing staff through. This includes the responsibilities of the Named Worker such as spending
time face to face with the person and those important to them, to collaboratively work out what might be
helpful in their situation and to determine the outcomes they want to achieve, what strengths and
resources they have to achieve these outcomes, and what interventions and support are available.
Furthermore, the need to provide targeted interventions, including relapse prevention as well as a focus
on robust discharge planning, 72 hour follow up after discharge from an inpatient mental health setting
and the provision of evidence-based interventions is also included in this work that commenced on the
12th June 2024. Supervision of individual members of staff following training is embedded into the model,
with audit and peer review processes to ensure new standards are being met. This aspect will commence
in October 2024. The Trust’s Transfer and Discharge from Mental Health and Learning Disability In-
Patient Care Policy CCR045b has been updated from June 2024 to reflect the changes.
Face to face rather than telephone appointments
As explained, in evidence at the inquest, face to face appointments are the default mode of treatment for
out-patient appointments and this is set out in standard work for the Named Worker. However, there will
be occasions where a remote appointment is considered to be more appropriate, for example, where this
is more convenient for patients, or the team are using alternative strategies to promote engagement.
Where a decision is made for an appointment to be undertaken remotely, the rationale must be provided
and documented. A quarterly audit process is being designed and implemented to ensure compliance with
this process. The results of this audit will be shared within the monthly Divisional Patient Performance,
Safety and Quality meeting (PPSQ).
Regularity and thresholds for MDT discussions
MDT (Multi-Disciplinary Team) meetings occur weekly within the Community Mental Health Teams and
are open to all staff to discuss concerns, complex cases, risk, safeguarding concerns, and discharges.
These meetings are structured to ensure comprehensive review and coordination of patient care. The
threshold for discussing cases in MDTs includes any significant change in a patient's condition, risk
factors, or treatment plan. Additionally, any concerns raised by family members or primary care providers
can be brought to these meetings for discussion. This priority system is in place as it is not feasible to
discuss every patient every week due the high number of patients being held on caseloads. There is
documented standard work for our MDT meetings which sets out the criteria for which cases should be
brought to this meeting.
In addition to regular MDT meetings, staff are encouraged to utilise other forums such as the Risk Panel
and the Complex Case Forum. These forums provide additional opportunities to address high-risk
situations and complex cases in a multidisciplinary setting, ensuring a thorough review and collaborative
approach to patient care.
Staff are also encouraged to utilise the Multiagency Risk Frameworks and other safeguarding frameworks
to ensure comprehensive risk management involving all relevant agencies and stakeholder especially
when concerns around medication concordance, safeguarding or engagement with services are identified.
This facilitates a multi-agency care plan to address issues. The provision of these various forums ensures
that staff have multiple avenues to address concerns, collaborate on care plans, and manage risks
effectively. For this particular case, a reflective workshop took place with the service involved to reflect on
the concerns and to ensure the learning is shared with the wider team.
Clear route for family to report concerns in absence of consent for information sharing with family.
Our existing policies, carers strategy, and training highlight the importance of hearing the family concerns,
even in the absence of consent to information sharing having been provided by the patient. Teams have
clear guidance on listening and collaborating with family within the Trust Risk Policy. If a family have
concerns that cannot be addressed by the team member these can be escalated to the MDT, Team
Manager or Clinical Director. The Trust complaints and PALS systems are also available if issues cannot
be resolved.
In addition, a new panel is being developed (for implementation in October 2024) in response to direct
feedback from carers that they would value an opportunity to have a voice and seek a second opinion on
care plans for their family when they are worried or have concerns. The panel will act in an advisory,
supportive capacity to carers/family. The panel's remit will be to:
▪ Provide a platform for carers to seek a second opinion or consultation regarding the care and
treatment of their family member under BHFT Mental Health Services
▪ Offer expert guidance, recommendations, and support to carers so they can better understand and
address the complex needs and challenges.
▪ To provide support and signposting to family members if they are worried about the patient’s condition.
Any carer may refer to the panel by completing a brief online form and assistance can be provided with
this by calling the number provided or sending an SMS message. If the criteria are met for participation a
date and time will be offered within 24 hours of a referral being received.
The criteria for referral will include:
▪ Where there is a concern about the patient and the carer does not feel heard by the treating team.
▪ Where, in the view of the carer, a proposed discharge from services presents a concern about risk and
unmet need.
▪ Where there is a lengthy or protracted admission that the carer is concerned may be causing harm.
▪ When a patient does not consent to information sharing but the family are worried and have not felt
supported by the treating team
Consent should be sought from the patient for their care to be discussed, however, in situations where the
patient does not consent, this will not be a barrier to the panel going ahead (whilst maintaining patient
confidentiality). Brief bullet points of action notes will be documented in the patient's record rather than
lengthy meeting minutes to ensure relevant points are easily captured.
For learning in this particular case, a reflective workshop took place with the service involved to reflect on
the concerns and to ensure the learning is shared with the wider team. Staff were reminded of the
importance of ensuring that families are informed about their right to share concerns and that these
concerns are discussed in the team to agree the most appropriate action.
Policy or expectation for correspondence with primary care after patient discharge
As mentioned above, the Trust’s Transfer and Discharge from Mental Health and Learning Disability In-
Patient Care Policy CCR045b has been updated in June 2024. This sets out expectations for staff in
relation to corresponding with the patient's GP on discharge, including ensuring the care plan is updated
to include the 72 hour follow up.
In addition to this our Interim Mental Health Care Planning and Treatment policy highlights the need to
liaise with the GP where there is a significant change in presentation, risk or care plan or where there are
issues relating to disengagement that may lead to discharge.
The workshop for this case, that took place on 4th June 2024, was facilitated by the clinical governance
lead, for reflection with the wider team and also highlighted the importance of clear communication,
medication monitoring and relapse prevention strategies.
Berkshire Healthcare takes the care and safety of its patients extremely seriously and is continuously
working to improve its practice to provide the highest possible standard of care. Representatives from
Berkshire Healthcare were present in court during the inquest to ensure that the learning from this matter
was captured and disseminated. I hope that this response provides some measure of reassurance to HM
Assistant Coroner and Mr Ellaboudy's family.
Yours sincerely
Chief Executive Officer
See every Prevention of Future Deaths report matching Berkshire Healthcare NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.