Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0291, written 29 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 | 29 May 2024 |
|---|---|
| Reference | 2024-0291 |
| Deceased | Hayley Cowan |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Mental Health related deaths |
| 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 DEATHS
THIS REPORT IS BEING SENT TO:
1. Rt Hon Victoria Atkins, Department of Health And Social Care, 39 Victoria Street,
London, SW1 H 0EU
2. Rt Hon James Cleverley Secretary of State for Ministry of Justice, House of Commans,
London, SW1A 0AA
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 22nd June 2022, I commenced an investigation into the death of Hayley Jayne Cowan. Hayley
died on the 4th June 2022. The investigation concluded on the 23rd May 2024. The medical cause of
death was confirmed as 1a) Adverse event arising out of mixed drug use
A jury concluded Hayley died as a result of misadventure.
4
CIRCUMSTANCES OF DEATH
Hayley had been detained under Section 3 of the Mental Health Act 1983 since July 2021. She had
a long history of involvement with mental health services and had previously been detained. She
had a diagnosis of Paranoid Schizophrenia and ADHD. Hayley was a risk to herself and others.
As well as her serious mental health illness, Hayley had a long history of illicit drug use.
In July 2021 having set fire to her flat she was detained at the Edenfield unit within Prestwich hospital
run by Greater Manchester Mental Health and Social Care Trust ("GMMH").
Hayley responded well to the re-introduction of her anti-psychotic medication and as part of her
therapeutic work she was granted Section 17 MHA'83 leave. There were times when her leave was
escorted and following progress it was on occasions unescorted.
Her leave also progressed from being on the hospital grounds to the local Tesco store opposite and
at times into the local village.
There had been at least two occasions when Hayley had absconded and run off from the staff with
her. She had taken drugs and then returned to the hospital.
At all times she was considered to be at risk of absconding which was driven by her urge to use
drugs.
On the 3rd June 2022 Hayley was granted accompanied leave with a support worker to the local
tesco store. Both Hayley and the support worker needed to use the bathroom and during this time
Hayley absconded. She was found deceased the following day, having used drugs at a friends
house where she had gone to. There was no guidance to staff as to what to do should they need to
use the bathroom. There was guidance given as to what to do should a patient need to use the
bathroom, therefore being out of sight.
By June 2022 the court heard that Borrowdale ward had introduced a practice of "accompanied
leave" by a band 2 suooort worker rather than the normal "escorted leave" with a band 3 worker who
would have received enhanced training. This was due to a shortage of band 3 workers and a desire
to facilitate patient leave.
5
CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion
In the circumstances· it is my
there is a risk that future deaths will occur unless action is taken.
statutory duty to report to you.
The MATTERS OF CONCERN are as follows:-
The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in
understanding and defining how Section 17 leave should be conducted. This issue was highlighted
in the paper published in December 2022
, "NHS mental health
services policies on leave for detained patients in England and Wales: A national audit." Journal
Psychiatric Mental Health Nursing 2023; 30: 719-730.
-
-
Local policies appear to be shaped as a result of capacity
There is a lack of consistency as to how "accompanied leave" and "escorted leave" are
defined.
- Guidance as to whether a patient should remain in "eye-line" or at a "reasonable distance"
is inconsistent and does not assist trusts in considering how trusts should
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust
policy are inconsistent. This is particularly the case in considering whether a patient needs to be
within "eyeline" or a "reasonable distance" when on leave. There is also no guidance as to how
trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom
whilst out with a patient.
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
July 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:-
- Greater Manchester Mental Health Trust
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: 29.05.24
V
-
, ..
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 Minister of State for Health 39 Victoria Street London SW1H 0EU 19 August 2024 Our Ref: Joanne Kearsley Senior Coroner HM Coroner's Court Floors 2 and 3 Newgate House Newgate Rochdale OL16 IAT By email: Dear Ms Kearsley, Thank you for your Regulation 28 report to prevent future deaths dated 29 May 2024 about the death of Hayley Jayne Cowan and I'd like to thank you for agreeing an extension. I am replying as the recently appointed 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 Hayley's death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. You have raised concerns about the lack of consistency and clarity for mental health trusts in understanding and defining how Section 17 leave should be conducted. I would like to assure you that we intend to address these issues and resolve the problem. My officials have consulted with NHS England which has shared the following updates on action that has been taken locally in the Trust in response to Hayley's death. 1. Greater Manchester Mental Health NHS Foundation Trust's adult forensic service had an escorting patient policy in place, however this has been updated to reflect the learning following Hayley's death. The use of accompanied leave has been discontinued with associated learning events and audits to evidence this. The Trust is reviewing both its escorting patient policy and Section 17 policy with a view to refreshing and combining these. 2. The adult forensic service had an induction programme in place for training staff on escorts, however this has been revised to be a standalone training resource. The service has also strengthened its staff competency framework for staff undertaking escorts and processes are in place whereby only staff who have been signed off to facilitate leave can do this role. 3. The adult forensic service has changed all care plan formats and enhanced the patient leave care plans. These are now explicit in terms of the multidisciplinary team assessing, reviewing and evaluating patient leave. Before each Section 17 leave, the nurse in charge undertakes a pre leave assessment and repeats this with a post leave review. 4. The service has also facilitated a quality improvement initiative to refresh the pre-leave assessment and ensure this is now person centred, focusing on key areas such as substance misuse and harm reduction. It has taken an assertive approach to ensure all patients who had previous/current substance misuse issues were assessed and provided with targeted interventions to reduce any harms associated with leave/substances. It has also developed a naloxone pathway for those who may be at risk of using substances whilst on leave. At national level, NHS England's mental health, learning disability and autism quality transformation programme is undertaking work focusing on personalised approaches to risk through relational care. This is based on the NICE Guidelines: Self Harm: assessment, management and preventing recurrence (2022) which identify that global risk assessment scales and tools should not be used to predict future suicide or repetition of self-harm. The findings from this work will be shared through learning networks and will help support the services to develop local policies on how they respond to risk on an individual basis. This work is part of a wider culture change programme that is aligned to the Culture of Care Standards for inpatient mental health services. Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work. I hope this response is helpful and that you are assured by the seriousness with which I take your concerns. Thank you for bringing them to my attention. Yours sincerely,
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