Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0332, written 20 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 | 20 Jun 2024 |
|---|---|
| Reference | 2024-0332 |
| Deceased | Shelemiah Peterkin |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| Category | Suicide (from 2015) · 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 THIS REPORT IS BEING SENT TO: CHIEF EXECUTIVE OF BIRMINGHAM AND SOLIHULL MENTAL HEALTH FOUNDATION TRUST CORONER I am Mr Adam Hodson, HM Assistant Coroner for Birmingham and Solihull 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. INVESTIGATION and INQUEST On 8 February 2024 I commenced an investigation into the death of Shelemiah Pedaiah PETERKIN. The investigation concluded at the end of the inquest. The conclusion of the inquest was: Suicide CIRCUMSTANCES OF THE DEATH On 02/10/2023, Shelley was reported missing by a friend. Following concerns for Shelley's welfare, police forced entry to her home at 23:45 where she was sadly found deceased, and she had clearly been deceased for some time. Post mortem and toxicological analysis confirmed that she died as a result of intentional consumption of had purchased off the internet. Shelley had been spoken to by police on 03/09/2023 about the reasons for the purchase and she had reassured them as to its use. She had a history of poor mental health and was under the care of the community mental health team at the time of her death. Shelley had missed her planned monthly depot injection on 18/09/23 and the mental health team were trying to locate her. There was a missed opportunity by the police to force entry to her home on 27/09/2023, but it is not possible to say whether she would have been found alive at that time. , which she Following a post mortem, the medical cause of death was determined to be: poisoning 1a 1b 1c II 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. – Matter 1 1 2 3 4 5 1. I heard evidence that there was a 6-day delay in the Community Mental Health Team team making a referral to the Home Treatment Team which was put down "clinical pressures". Upon discussion, these "clinical pressures" related to staffing levels and the evidence was that at the time the team was meant to have 7 clinical members of staff but only had 3. I was told that matters have improved somewhat and that now there is sufficient staffing levels. 2. However, it was confirmed that gaps in staffing levels do occur which can have a knock-on effect of causing issues with service delivery and care for patients. 3. It is not difficult to foresee that inadequate staffing levels will give rise to missed opportunities for patients to be assessed; for interventions to take place; and for treatments to be given - particularly where patients may choose to disengage with services but who do not demonstrate any "red flags" or early warnings, as was the case with Shelley. 4. As such, I am concerned about the risk of future deaths occurring if staffing issues arise in the future. Matter 2 1. I heard evidence from the Structured Judgment Review that a learning point was identified that early warning signs were not completed to the required expectation or standard. 2. As such, an Action Plan was prepared and a task was agreed that this would be discussed at the Trust Risk and Task Finishing Group to establish clear clinical standards, with the same then being disseminated within the Trust. This was allocated to the Clinical Service Manager for ICCR and was due to be completed by May 2024. 3. In evidence, it was confirmed that target had been missed due to a meeting being cancelled, but assurance was offered that it would take place in July - after the inquest has concluded. 4. I am concerned that if this target is pushed back and/or is not met, for whatever reason, there is a risk that future deaths will occur. Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced. It is for you and your organisation to take the action that is required to resolve the issues and to prevent future patients from dying avoidable deaths. It is not for me as Coroner to make recommendations on how you do that, therefore I leave matters in your hands. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 August 2024. I, the coroner, may extend the period. 6 7 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (Next of Kin) I have also sent it to the ICS and NHS England 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. 20 June 2024 8 9 Signature: Adam Hodson Assistant Coroner for Birmingham and Solihull
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.
Legal Department Uffculme Centre 52 Queensbridge Road Moseley Birmingham B13 8QY Tel: Mr Adam Hodson, Deputy Coroner, Birmingham and Solihull Areas, BIRMINGHAM B4 6BJ BY EMAIL ONLY TO: Our Ref: Your Ref: Date: 29 July 2024 Dear Mr Hodson, Re: Prevention of Future deaths Shelemiah Peterkin Thank you for your Prevention of Future Deaths report dated 20 June 2024 with. May I begin by offering my sincere condolences to Shelemiah’s family. I understand that explanations were given during the inquest to offer assurances that lessons have been learned, but further information has been requested through your Prevention of Future Deaths report. I will aim to respond to each of your points in turn. Matter 1- Relating to staffing Since this time, Lyndon CMHT has successfully recruited into all vacant posts. Additional investment into the team has also taken place as a result of Community Mental Health Transformation, this has increased the workforce capacity within the team, these roles have also been recruited into. With the additional funding and successful recruitment into all vacant posts, it is unlikely that the team will face inadequate levels of staffing in in the immediate future. If however this was to occur, there is a clear escalation process in place that would ensure a timely review of any gaps and would support the development of a clear plan to mitigate the identifed risks. Matter 2- Early Warning Signs This was discussed at the Clinical Risk Processes Group on 13th June 2024, with a further meeting chaired by the Deputy Medical Director and Head of Patient Safety on 21st June 2024. It was agreed that Early Warning Signs is a core skill of those who have undertaken clinical training, and that further support for this will be incorporated into the DIALOG+ (care planning and safety planning) training for staff which is currently underway. Additionally, the current CPA Part B Care Plan and the new Dialog+ Safety Plan have been reviewed and there are information and descriptor sentences already built into these forms to indicate the expected standard for the description of an Early Warning Sign. There are processes in place for teams to review the completion and quality of Care Plans through audits and clinical supervision. Chair: │ Chief Executive: │ Website: www.bsmhft.nhs.uk Customer Relations: Mon–Fri, 8am–6pm │ Tel: │ Email: bsmhft.customerrelations@nhs.net I sincerely hope that this has offered you the reassurances that the Trust takes learning very seriously and actions taken are followed up. Yours sincerely Chief Executive BSMHFT 2
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