Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0320, written 14 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jun 2024 |
|---|---|
| Reference | 2024-0320 |
| Deceased | Amina Ismail |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Victoria Aitkins, Secretary of State for Health and Social Care, Department of
Health and Social Care, 39 Victoria Street, London SW1H 0EU.
2.
B97 9PT
1
CORONER
, Chief Executive, NHS England, PO Box 16738, Redditch
I am Andrew Bridgman, Assistant Coroner, for the coroner area of South Manchester
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 18.09.23 an investigation commenced into the death of Amina Ahmed Ismail who
died on 15.09.23 at Pankhurst Ward, Priory Hospital Cheadle, aged 19 years having
been born on 08.06.03. Amina had self-ligatured. Pankhurst Ward is a PICU – where
Amina had been a patient from August 2022.
Interested Persons
In addition to Amina’s family the Interested Persons were
The Priory Hospital, Cheadle
Birmingham Women and Children Hospitals NHS FT – otherwise known as Forward
Thinking Birmingham (‘FTB’)
Birmingham and Solihull Integrated Care Board (‘the ICB’).
The inquest was held as an Article 2 inquest with a jury; Amina was a detained patient.
The inquest concluded on 16.05.24.
The medical cause of death was:
1a) Ligature Strangulation
1b)
1c)
2 Emotionally Unstable Personality Disorder, Post Traumatic Stress Disorder
The conclusion of the jury was:
Misadventure
In answer to the question how Amina came by her death the jury recorded:
Amina was ready for step-down in September 2022, but was subject to a prolonged stay
on the PICU ward due to the shortage of appropriate, specialist care beds. Amina's
mental health deteriorated during her long PICU stay. These factors contributed to the
circumstances of Amina's death.
.
4
CIRCUMSTANCES OF THE DEATH
Amina lived in Birmingham. At the age of 15 years Amina was admitted to Orchard
1
Ward, Priory Hospital Cheadle (adolescent acute ward) on 02.01.19, under section 2 of
the MHA 1983, following an overdose, and then section 3 of the Act. From there
Amina’s journey was to Mulberry Unit, Priory Hospital Woodbourne (adolescent acute
ward) in February 2019, from there to Meadows Unit, Priory Hospital Cheadle
(adolescent PICU) with discharge back into the community in September 2019.
Amina was admitted to Pegasus Ward, Cygnet Sheffield (adolescent acute ward) on
18.06.20, aged 17 years, following an overdose of her medications under section 2 of
the Act From then until her death, some 2 years 3 months later, Amima was a detained
patient on mental health units distant from her home, family and friends.
On 23.07.20 Amina was transferred from Pegasus Ward to Unicorn, Cygnet Sheffield, A
PICU, where she remained for 5 months.
In December 2020 Amina was transferred to a low secure unit in Ebbw Vale, South
Wales, where she stabilised.
On 22.11.21 Amina was transferred to a specialist Personality Disorder Unit at Cygnet
Nield House, Crewe to commence Dialectical Behavioural Therapy (DBT).
In mid-June 2020 Amina’s mental health deteriorated and her incidents of self-harm
worsened. Nield House advised FTB (‘the home team’) that it could no longer keep
Amina safe and that a PICU was required.
It took until 01.08.22 for FTB to locate a PICU that was able to, and would, accept
Amina.
On 02.08.22 Amina was transferred to The Priory Hospital, Cheadle.
Other than her brief time at The Priory Hospital, Woodbourne all of Amina’s placements
were out-of-area.
Amina was ready for step-down from the PICU, at The Priory Cheadle, in early
September 2022. Nield House would not re-admit Amina without a further assessment,
and in any event, had Amina then been accepted FTB would have needed to re-apply to
the ICB for funding of her placement at Nield House.
FTB decided to carry out a PACT assessment to re-determine Amina’s needs in order to
ensure that the next placement would be the most appropriate. Failure of another
rehabilitation placement would be devastating for Amina.
That assessment was commenced in October 2022 and was complete by early January
2023.
There was consideration of Fern Unit, a specialist Personality Disorder Unit at Priory
Cheadle but it was felt that its DBT programme was too rigid for Amina’s needs.
Following completion of the assessment FTB sought a suitable rehabilitation placement.
At the time only two independent providers had capacity to take Amina. One of those,
Cygnet Alders Ward turned Amina down as it did not think Amina was sufficiently stable.
The other one, Equilibrium Eleanor House in Manchester. was prepared to accept
Amina after carrying out its own assessment. On 15.03.23 the FTB applied to the ICB for
funding to transfer Amina to Eleanor House, which at the time had voluntarily closed
itself to patients following a CQC rating of overall inadequate, and was appealing a
Notice of Decision, to be heard in June 2023. The application was turned down by the
ICB on 04.05.23. The ICB provided the FTB with 3 other potential placements,
Cygnet Kewstoke: Weston-Super-Mare
Elysium Gateway: Widnes
Priory Middleton St George: Durham.
None of these units were prepared to consider Amina because of the acuity of their
2
current patients.
Upon being told that funding for Eleanor House had been declined there was a
significant downturn in Amina’s mental stability evidenced by a re-emergence of
ligaturing as a coping mechanism, and for the following 10 weeks was monitored on
enhanced level observations. By mid-July Amina had stabilised.
During that period the option of transferring Amina to a local PICU, with input from the
local mental health in-reach team was explored, but there were no local PICU female
beds available. There being only 6 such beds locally, commissioned exclusively by FTB
at The Priory, Barnt Green.
In July 2023 The Priory (the treating team) and FTB (the home team) and Amina felt that
she was stuck.
Further consideration was given to Fern Unit. Following assessment, and with some
flexibility introduced into the DBT programme, Amina was accepted by Fern Unit on
31.08.23. At a Ward Round on 06.09.23 both the Pankhurst Ward team and FTB felt that
the transfer would be appropriate. Amima was noted to be looking forwards to the
move. A peer from Pankhurst Ward had already been transferred.
Although a bed was immediately available FTB needed to complete an application for
funding the Fern Unit to the ICB. That had not been commenced at the time of Amina’s
death but had it been it is unlikely, even if commenced on 06.09, that funding would
have been approved in time to allow transfer before her death.
The evidence of the Responsible Clinician at The Priory, Cheadle and the Court
appointed expert was that there was an overall deterioration in Amina’s mental health
during her prolonged admission on the PICU; it was not an appropriate environment, she
was not able to have the necessary therapy, although Amina received psychological
input it was limited (by the fact of being in PICU) and by July/August Amina had stopped
learning and was not using coping mechanisms that she had developed in her
psychology sessions.
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. –
This is now the third inquest (two within the past 8 months) I have heard where the
delayed transfer of an out-of-area patient from an independent provider’s hospital has
been a contributory factor in that patient’s death. Two of those cases involving
prolonged stays on PICU units; in this case some 13 months and in the other, some 11
months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at
Nield House (where the treating team felt that they could not keep Amina safe) to a
PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory,
Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds
whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from treating two treating psychiatrists in Amina’s
3
history (Nield House and The Priory), FTB PACT assessor, and the court appointed
independent expert that there was, and is, a national shortage of specialist PD
rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding
what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’
mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients
as Amina – transfers not being accepted by such units even if not full because the
acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from
home, family and the
its own admission
Each having
team.
local/home
criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD
units that had a bed available. One of them, Eleanor House, was re-opening its
doors having voluntarily closed at the end of 2022.
It had 14 beds available.
However, its extant CQC rating was overall inadequate and it was in the process of
appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without
any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was
wholly unsuited to her presentation and unable (through no fault of its own) to
deliver the care and therapy that she needed resulting in a deterioration in her
mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health
care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both
community and in-patient. FTB are able to commission NHS and independent
sector acute beds and PICU’s, both in and out of area. However, FTB are not able
to commission specialist placement,
These are
commissioned/funded directly by the ICB upon application by the FTB; having found
a unit that would accept a patient.
including PD units.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in
light of the shortage of such specialist/rehabilitation beds. The inquest heard
evidence that the process from application to funding approval takes weeks,
sometimes months.
In this case it took from 13.03.23 to 04.05.23 for a negative
outcome.
The shortage of beds/units means that when a bed becomes available there are a
number of patients in competition for it. The beds are not kept open for any
particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to
provide secondary mental health services is not permitted to make its own funding
decisions for specialist units, as it can for acute wards and PICU’s. As can be seen
from the evidence Amina was able to be transferred within 24hrs once a PICU
accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a
PICU bed.
6
ACTION SHOULD BE TAKEN
Unless action is taken to increase the number of mental health beds (beds, PICU) and in
particular specialist/rehabilitation units, in general but particularly within area, more of
4
our most vulnerable members of society are going to be sent to mental health units
unacceptably distant from their homes, family and friends, be unable to receive the
treatment they need, suffer an associated deterioration in their mental state with an
increased risk of deliberate or accidental self-inflicted death.
In my opinion action should be taken to prevent future deaths and I believe you 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.
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, who may find it useful or of interest.
1. Amina’s family
2. The Priory Cheadle
3. Birmingham Women and Children Hospitals NHS FT – otherwise known as
Forward Thinking Birmingham
4. Birmingham and Solihull Integrated Care Board.
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 this 14th day of June 2024
Andrew Bridgman
HM Assistant Coroner
5
2 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.
From Baroness Merron Parliamentary Under Secretary of State For Patient Safety, Women’s Health and Mental Health. 39 Victoria Street London SW1H 0EU 3 September 2024 Our Ref: Andrew Bridgman Assistant Coroner for South Manchester 1 Mount Tabor Street Stockport SK1 3AG By Email: Dear Mr Bridgman, Thank you for your Regulation 28 report to prevent future deaths dated 14 June 2024 about the death of Amina Ahmed Ismail. I am replying as the Minister for Patient Safety, Mental Health and Women’s Health. Firstly, I would like to say how saddened I was to read of the circumstances of Amina’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. I understand your concerns about the funding of mental health services, the reliance by the NHS on independent providers for mental health beds and the availability and funding of specialist personality disorder rehabilitation units. I note that you have also addressed these matters of concern to the Chief Executive of NHS England. I look forward to seeing her response and working with NHS England where appropriate, to avoid a repetition of the tragic events of this case. I recognise the impact that a suitable bed not being available can have on a patient’s care, as exemplified in Amina’s case. I am sure you will appreciate that the number of mental health inpatient beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an inpatient admission being necessary. I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist personality disorder rehabilitation units. I understand that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity. A4 1 Over the past few years, the NHS has been developing the community mental health framework to improve community support for people with severe mental illness, thus avoiding the need for an inpatient admission where possible and freeing up more beds. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with local health systems directed to reduce the average length of stay in adult acute mental health wards to deliver more timely access to local beds. And in areas where there is a clear need for more beds, this has been addressed in part through investment in new units, as part of a this whole system transformation approach. As part of our mission to build an NHS fit for the future , we will make sure mental health care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. Turning to your concerns around the reliance by the NHS on independent providers for mental health beds, independent providers have always played a role in the NHS and I am clear that patients should expect a safe and good quality service regardless of whether their care is delivered by independent sector or public sector providers. In 2022 NHS England launched the mental health, learning disability and autism inpatient quality transformation programme. A core aim of the programme is to localise and realign care, harnessing the potential of people and communities. The programme is built upon the cornerstones of good mental healthcare; continuity of care, therapeutic relationships and a commitment to mental health care meeting the needs ofthe population. All integrated care boards have been tasked by NHS England with developing 3-year plans to localise and realign inpatient mental health care, including NHS-funded care provided by the independent sector, as part of this programme. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, BARONESS MERRON A5
Mr Andrew Bridgman HM Assistant Coroner Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 05/08/2024 Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Amina Ahmed Ismail who died on 15 September 2023. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 14 June 2024 concerning the death of Amina Ahmed Ismail on 15 September 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Amina’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Amina’s care have been listened to and reflected upon. Your Report raises concerns over delayed transfers of out-of-area patients from an independent provider’s hospital, who are in need of in-patient mental health care services, along with the number of available mental health beds (including PICU beds) and specialist / rehabilitation units within a patient’s local area. In 2022, NHS England launched the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme. A core aim of the programme is to localise and realign care, harnessing the potential of people and communities. The programme is built upon the cornerstones of good mental healthcare; continuity of care, therapeutic relationships and a relentless commitment to mental health care meeting the needs of all citizens. To support this aim, NHS England published the Commissioning Framework for Mental Health Inpatient Services in early 2024 and introduced a requirement in its Operational Planning Guidance (2024/25) that each Integrated Care Board (ICB) develop and publish a 3 year plan to localise and realign care to the evidence-base summarised in the Framework. Local plans need to cover within them how they will cease the practice of sending people to inpatient services at a distance from their home and/or to outdated or risky models of provision – underpinned by the philosophy that ‘all means all’, and people with acute mental health needs should have access to the evidence-based therapeutic offers they need as close to home as possible and adjusted to their needs. This includes acute and rehabilitation inpatient services. Final ICB plans are due for publication, and £42 million recurrent funding has been provided to ICBs to support delivery. This sits alongside work focused on improving the culture of inpatient services. In 2024, NHS England launched a universal Culture of Care Improvement Programme, A1 partnering with the National Collaboration Centre for Mental Health and the Foundation of Nursing Studies (as well as a consortium of other organisations). The Improvement Programme includes six support offers which all NHS and major Independent Sector providers have subscribed to. These include a Ward Manager Development Programme, support on personalised risk and safety planning, and a universal Staff Support Offer. The Culture of Care Improvement Programme is based upon co-produced Culture of Care Standards for Mental Health Inpatient Services, where the purpose of inpatient care is for people to be consistently able to access a choice of therapeutic support, and to be and feel safe. We have also contacted our regional colleagues in the North West who have engaged with the Greater Manchester Integrated Care Board (GM ICB), who have oversight of The Priory Cheadle. The Stockport Safeguarding Partnership Board and Stockport Locality Group have had full oversight of the learnings from Amina’s care and a Serious Adult Review is in progress. GM ICB’s oversight currently includes: • Monthly assurance visits that take place to review key lines of enquiry, looking at metrics and a key focus for that month. • Bi-monthly relationship meetings with the hospital director. • The Priory is involved in system deep dive work. • Monthly catch ups with the Local Provider Collaborative to ensure triangulation of intelligence. • Escalation of support around patients who are medically optimised and ready for discharge. My regional colleagues in the Midlands have also been made aware of this case, and we note that Birmingham and Solihull Integrated Care Board, and the providers involved in Amina’s care, are named as interested parties in your Report. 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 Amina, 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, A2 National Medical Director A3
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