Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0282, written 21 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 | 21 May 2024 |
|---|---|
| Reference | 2024-0282 |
| Deceased | Emma Morris |
| Coroner | Sarah Murphy |
| Coroner area | Cheshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 NHS England 1 CORONER I am Sarah MURPHY, Assistant Coroner for the coroner area of Cheshire 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 29 September 2023 I commenced an investigation into the death of Emma Louise MORRIS aged 39. The investigation concluded at the end of the inquest on 15 May 2024. The conclusion of the inquest was that: Suicide 4 CIRCUMSTANCES OF THE DEATH Emma Morris had a medical history of anxiety and depression. She had suffered a deterioration in her mental health and on the 20th September 2023, deliberately walked in front of a bus on the slip road of junction 39, Chester, heading towards the A55. A gatekeeping assessment had been completed by a mental health practitioner of the Crisis Resolution and Home Treatment Team on the 19th September where the practitioner found that an informal inpatient admission to a mental health ward was clinically indicated, but this could not be facilitated immediately as there were no beds available nationally. She was therefore under the care of the Crisis Resolution Home Treatment Team at the time of death. 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: (brief summary of matters of concern) The gatekeeping assessment included a mental health state examination, where it was the clinical opinion of the mental health practitioner from the Crisis Resolution Home Treatment Team, that Ms Morris required an inpatient hospital admission to a mental health ward as there was an immediate risk to her safety as she was found to be a high risk of walking in front of a car. Whilst Ms Morris agreed to an informal admission, this was not possible at the time of assessment as there were no beds available nationally within the NHS or privately. As an inpatient admission was not possible, the option was to attend the Accident and Regulation 28 – After Inquest Document Template Updated 30/07/2021 Emergency Department or to remain in the community whilst waiting for an inpatient mental health bed to become available. Ms Morris had been informed that if she attended the Accident and Emergency Department, there could be a wait of three days for an inpatient mental health bed to become available. Ms Morris did not wish to wait in the Accident and Emergency Department for three days. A safety plan was agreed that Ms Morris would stay overnight with a family member, and would remain under the care of the Crisis Resolution Home Treatment Team who would review the following morning. The family felt that it was pushed for Ms Morris to stay overnight with a family member as there was no alternative to keep her safe. During the course of the inquest, I heard that there is national pressure on hospital trusts as there is a national increase in people waiting for inpatient beds. I am therefore concerned that there is a risk of future deaths as it is not possible to access inpatient mental health beds at the time of clinical need. 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by July 15, 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 The family of Emma Morris Cheshire and Wirral Partnership NHS Foundation Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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: 21/05/2024 Sarah MURPHY Assistant Coroner for Regulation 28 – After Inquest Document Template Updated 30/07/2021 Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Ms Sarah Murphy
Assistant Coroner for the area of Cheshire
The West Annexe
Town Hall
Sankey Street
Warrington
Cheshire
WA1 1UH
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
15 July 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Emma Louise Morris who
died on 20 September 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 May
2024 concerning the death of Emma Louise Morris on 20 September 2023. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Emma’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Emma’s care have
been listened to and reflected upon.
Your Report raises concerns over the national shortage of inpatient mental health beds
and the risk of future deaths if people cannot access them at the time of clinical need.
In Emma’s case, she had been assessed as requiring an inpatient hospital admission
to a mental health ward, and she had agreed to an informal admission, but there were
no beds available nationally within the NHS or privately at that time.
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 system1 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 there is a need for more beds. This is being addressed in part
through investment in new units but should also be considered as part of a whole
system transformation approach.This is supported by the NHS Long Term Plan
(LTP), which is seeing an additional £2.3 billion funding being invested in mental
health services from 2019/20 – 2023/24, around £1.3 billion of which is for adult
community, crisis and acute mental health services to help people get quicker
access to the care they need, and to prevent avoidable deterioration and hospital
admission. NHS England’s 2024/25 priorities and operational planning guidance
reinforces this focus on improving patient flow as a key priority, with systems
directed to reduce the average length of stay in adult acute mental health wards, in
order to deliver more timely access to local beds.
1 NHS England » What are integrated care systems?
To address the wider system issues that impact on health services, a further £1.6
billion has been made available via the Better Care Fund (‘BCF’) from 2023-25. This
funding 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.
My colleagues within the central Medical Directorate are also seeking further
information from the North West region, in respect of Cheshire and Merseyside
Integrated Care Board’s system arrangements for mental health beds.
I would also like to provide further assurances on the 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 events, such as the sad death of
Emma, are shared across the NHS at both a national and regional level and helps us
to 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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