Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0254, written 9 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 May 2024 |
|---|---|
| Reference | 2024-0254 |
| Deceased | Brandon Turner |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Suicide (from 2015) |
| Organisation named | Cornwall 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.
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. The Rt Hon Victoria Atkins MP, Secretary of State for Health , Chief Medical Officer, CIOS ICB and Social Care 1 CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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. 3 INVESTIGATION and INQUEST On 9 May 2024, I concluded the inquest into the death of Brandon William Turner, also known as Amelia Turner, who died on 21/6/23 at the age of 21. In accordance with the wishes of his mother who attended inquest, I shall refer to him hereafter as Brandon. I recorded the cause of death as 1a) Asphyxia 1b) Fatal pressure on the neck; II) PTSD; Autism I concluded Brandon died from suicide. 4 CIRCUMSTANCES OF THE DEATH Brandon had suffered adverse childhood experiences including neglect and emotional abuse that led to his adoption along with his brother. As he grew into adolescence and then early adulthood mental health difficulties emerged that led to a diagnosis of complex PTSD/emotionally unstable personality disorder. Additionally, he had a diagnosis of autistic spectrum disorder. In total, Brandon had five Mental Health Act assessments between May 2021 and May 2023, to include two on consecutive days on 14 and 15 May 2023, the latter following detention under s136. I heard at inquest that it is contrary to national guidance and local policy to admit someone with PTSD/EUPD into hospital and, absent any other therapeutic option, the consultant psychiatrist referred Brandon to the local CMHT. He was discussed at MDT on 23/5/23 and a duty worker spoke to him on 16/6/23 when a decision was made to put him on the 1 Information Classification: CONTROLLED CMHT therapy pathway. He was found deceased five days later before any treatment had commenced. On reflection, it was noted that referrals would aim to be actioned within five days but took 16 here. The inquest heard that the CMHT was short- staffed at the time and the Manager concerned was fulfilling two roles. 5 CORONER’S CONCERNS During the course of these inquests, the evidence has 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) Shortage of staff. This has been a longstanding concern in Cornwall. I am aware there have been initiatives undertaken nationally and internationally and yet the problem remains. It seems this is not an issue that can be resolved by the local ICB and so this concern is directed to the Secretary of State for her attention and formal response. The following two issues require a response from the ICB and not the Secretary of State. (2) As noted above, the inquest was informed that where patients with complex PTSD/EUPD present in crisis, national and local practice is not to detain in a secure hospital. The inquest also heard that in other areas of the country there is a therapeutic alternative of admission to a day hospital (ie not detained, but somewhere to permit de-escalation) or to a crisis unit/house/café. That option is not currently available in Cornwall. (3) The inquest heard that CPFT is commissioned to assess 140 patients annually for autism. The current waiting list for assessment is in the region of two years. In other words, the demand for the service greatly exceeds the current supply. 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. In relation to (1) above, may I invite the Secretary of State to consider how the persistent shortages of staff within the mental health service in Cornwall may be remedied. In relation to (2) and (3), may I invite the ICB to consider whether the concerns identified require attention, acknowledging that there will be other competing concerns. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6 July 2024. I, the coroner, may extend the 2 Information Classification: CONTROLLED 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: - mother 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 [DATE] [SIGNED BY CORONER] 9/5/24 3
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.
Executive office 2S, Chy Trevail, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2FR Email: 27 December 2024 STRICTLY PRIVATE & CONFIDENTIAL Mr Andrew Cox Senior Coroner for Cornwall & the Isles of Scilly Cornwall Coroners' Service Pydar House, Pydar Street, Truro, TR1 1XU Dear Mr Cox Re: Brandon William Turner (Ref: 16120916) I am writing on behalf of NHS Cornwall and Isles of Scilly integrated care board (ICB) in response to the regulation 28 report relating to the care of Brandon William Turner, known as Amelia. As per our letter of 15 August 2024 where we committed to updating you as to progress with our actions, we offer the following update. One of your concerns was related to the lack of therapeutic alternative options within Cornwall for those experiencing complex Post traumatic stress disorder (PTSD) and emotionally unstable personality disorder (EUPD) who present in crisis. This issue has been recognised by our health and care system and a 24/7 crisis care pathway is in development in a phased and scaled manner. Initially, we have opened a reablement bedded unit with a block purchase of 4 beds. In addition to this, a community reablement service has been made available where an inpatient bed is not appropriate or warranted. The service includes the option for admission avoidance and crisis sanctuary, to drive improvement and prevent mental ill health crisis in a resilient, recovery and trauma informed way. Whilst not a dedicated PTSD / EUPD service, the new service is inclusive and would be open to people that have PTSD / EUPD supporting the aims further set out in the letter. Cornwall council provide a range of services that deliver mental health support for adults, children, young people, families and carers. There are also existing joint health, care and VCSE projects. It is therefore important within our planning to ensure these services continue to work in partnership and provide services that interact to deliver a range of options, including crisis sanctuary, for those who need it. The service criteria is inclusive with accessibility to those with a set of needs that meet the safety principles and is not based on diagnosis. The aims of the proposal include: • • • • • Supporting the prevention of mental health crisis Reducing inappropriate conveyance or attendance to Emergency Departments (ED) Avoiding unnecessary Section 136 conveyances Support prevention of admission to hospital, in general Minimise acute out of area placements, specifically The approach would also: • • • Provide wellbeing activities and support Support recovery Support integration or reintegration into local communities It is important that the delivery of this care is well planned if we are to ensure it meets the requirements we have set out. Work continues to develop this, at pace, and confirm a sustainable funding source for the scheme, but mental health investment remains a core priority for the NHS, so we would expect this to be prioritised from future investments made in line with the national Mental Health Investment Standard requirements. Whilst we may not be able to give you full assurance of the action and timescales immediately, we would like to keep you informed as the work progresses. ICB commissioning intentions include an upscaling of the current project above to include sanctuary support for autistic people and day reablement support on site. The commissioning intentions also include a commitment to developing our Crisis Resolution Home Treatment Team (HTT) further by expanding the 24/7 delivery of the service. Clients who are suffering poor mental health also have access to an admission avoidance bed in the East of the county and a new initiative called Supportive Stays in which families invite individuals into their homes for up to 8 weeks to prevent mental health decline. All admission alternative resources are overseen by our HTT and delivered by Voluntary, Community and Social Enterprise (VCSE) partners. The planning for these intentions involves a broad range of partners, including the ICB, Cornwall Partnership NHS Foundation Trust (CFT), Cornwall Council, local GPs and number of voluntary and community sector (VCSE) organisations. We hope this update provides further assurance regarding the focus and priority given to improving our mental health and autism services with the support of our partners across the health and care system. Yours sincerely Chief Executive Page 2
Executive office 2S, Chy Trevail, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2FR Email: ciosicb.coroners@nhs.net 15 August 2024 STRICTLY PRIVATE & CONFIDENTIAL Mr Andrew Cox Senior Coroner for Cornwall & the Isles of Scilly Cornwall Coroners' Service Pydar House, Pydar Street, Truro, TR1 1XU Dear Mr Cox Re: Brandon William Turner (Ref: 16120916) I am writing on behalf of NHS Cornwall and Isles of Scilly integrated care board (ICB) in response to the regulation 28 report relating to the care of Brandon William Turner, known as Amelia. Our thoughts remain with the family. One of your concerns was related to the lack of therapeutic alternative options within Cornwall for those experiencing complex Post traumatic stress disorder (PTSD) and emotionally unstable personality disorder (EUPD) who present in crisis. This issue has been recognised by our health and care system and plans are being developed for the establishment of a 24/7 crisis care pathway, which would include crisis sanctuary, to drive improvement and prevent mental ill health in a resilient, recovery and trauma informed way. The planning for this involves a broad range of partners, including the ICB, Cornwall Partnership NHS Foundation Trust (CFT), Cornwall Council, local GPs and number of voluntary and community sector (VCSE) organisations. The intention is to create a new and complementary service, to work alongside existing services provided by CFT, Cornwall Council and VCSE partners. Cornwall council provide a range of services that deliver mental health support for adults, Children, young people, families and carers. There are also exiting joint health, care and VCSE projects. It is therefore important within our planning to ensure these services continue to work in partnership and provide services that interact to deliver a range of options, including crisis sanctuary, for those who need it. The service criteria will be inclusive with accessibility to those with a set of needs that meet the safety principles and not based on diagnosis. The aims of the proposal include: • • • • • Supporting the prevention of mental health crisis Reducing inappropriate conveyance or attendance to Emergency Departments (ED) Avoiding unnecessary Section 136 conveyances Support prevention of admission to hospital, in general Minimise acute out of area placements, specifically The approach would also: • • • Provide wellbeing activities and support Support recovery Support integration or reintegration into local communities Plans are progressing with clinical staff from CFT to ensure robust training and supervision is in place for VCSE staff members and to agree the level of clinical provision within the unit. There is also agreement for the Primary Care Network to co-locate at the premises and provide GP cover. The plans would be expected to include 24-hour support from trained workers and access to Mental Health clinicians where required. It is important that the delivery of this care is well planned, if we are to ensure it meets the requirements we have set out. Work continues to develop this, at pace, and confirm a sustainable funding source for the scheme, but mental health investment remains a core priority for the NHS, so we would expect this to be prioritised from future investments made in line with the national Mental Health Investment Standard requirements. Whilst we may not be able to give you full assurance of the action and timescales immediately, we would like to keep you informed as the work progresses. Your second concern for ICB response relates to the commissioning of assessments from Cornwall Partnership Foundation Trust (CFT) noting that demand exceeds available provision. The ICB has sought to mitigate this in part through the commissioning of an autism intensive support service (AIST) and autism diagnostic service from CFT. However, we accept that further mitigation is required and collectively we are working together to develop a plan to address the unmet demand locally. Whilst we develop intentions, increasing numbers of people are accessing services through the ‘Right to Choose’ initiative whereby GPs can refer people who have been waiting longer than 18 weeks to another provider that does have capacity to provide a service. Under these arrangements we are working through contractual changes to ensure consistency of provision and intend to enact these in the latter half of the year, with these providers. We hope this provides some assurance regarding the focus and priority given to improving our mental health and autism services with the support of our partners across the health and care system. We will commit to reporting back to you with an update on the progress of these actions by 31st December 2024. Yours sincerely Chief Executive Page 2
From Maria Caulfield Parliamentary Under-Secretary of State for Mental Health and Women's Health Strategy 39 Victoria Street London SW1H 0EU 28 June 2024 Andrew Cox Senior Area Coroner Cornwall and Isles of Scilly Cornwall Coroner’s Service, Pydar House Pydar Street Truro, Cornwall TR1 1XU Dear Andrew, Thank you for your Regulation 28 report to prevent future deaths dated 9 May 2024 about the death of Brandon William Turner. 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 Brandon’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 at national level over shortages of staff. We understand that that staff shortage is an ongoing and significant challenge for Cornwall with high use of Agency staff over recent years. Cornwall Partnership NHS Foundation Trust is developing a workforce strategy to address recruitment challenges. The Trust is in the process of setting up a facility in Truro run by the CHAOS Group which will have up to 14 step up / step down beds, 4 crisis beds, a 24/7 crisis/sanctuary facility plus support at home. This will be opened in a phased approach with the support at home function planned to start from 1 July. Although Cornwall is not currently operating a crisis café, there is limited provision of sanctuary house support which can be accessed via the Trust’s Crisis Resolution and Home Treatment Teams services, as part of an integrated service offer. The ICB, in partnership with Cornwall Council, has recently awarded a 5 year contract to provide a VCSE mental health and suicide prevention collaborative to deliver integrated, place-based support in communities for those who may be vulnerable or feel at risk. This service is called ‘People in Mind’ and is delivered via the Voluntary Sector Forum (VSF). This new service should be integrated with existing crisis pathways in cases where individuals need to be escalated to more intensive support. We know that waits for autism assessments are very long, with many private providers coming into the market and Cornwall isn’t unique to this. NHS Cornwall and the Isles of Scilly Integrated Care Board and the Trust have developed plans to reduce the waiting times to access autism services and those on the waiting list should be made aware of how to access support should they feel vulnerable or at risk. It should be noted that if an autistic person is requiring or requesting support for a mental health condition all reasonable adjustments should be made to support timely access to evidence-based support. Turning to your concerns around the impact of staffing shortages on service delivery nationally, the Government recognises the need to increase workforce capacity in NHS mental health services overall. Positive progress has been made on growing the mental health workforce which, as of December 2023, had increased by around 20,800 compared to 2019/20. In addition, the NHS Long Term Workforce Plan sets out an ambition to grow the mental health, primary and community care workforce by 73% by 2036-37. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD
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