Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0337, written 24 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 | 24 Jun 2024 |
|---|---|
| Reference | 2024-0337 |
| Deceased | Liam McCarlie |
| Coroner | Jonathan Dixey |
| Coroner area | Northamptonshire |
| Category | Suicide (from 2015) · Emergency services related deaths (2019 onwards) |
| Organisation named | Northamptonshire Healthcare NHS Foundation Trust · East Midlands Ambulance Service NHS Trust |
| 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: (1) EAST MIDLANDS AMBULANCE SERVICE NHS TRUST (2) NHS NORTHAMPTONSHIRE INTEGRATED CARE BOARD 1 CORONER I am Jonathan Dixey, assistant coroner, for the coroner area of Northamptonshire. 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 5th April 2023 an investigation was commenced into the death of Liam Paul McCarlie. On 5th June 2024 I concluded the inquest into Mr McCarlie’s death. The conclusion of that inquest was a narrative conclusion: Liam Paul McCarlie died by suicide. From 15 February 2023 there was an insufficiently clear plan to support proactively Mr McCarlie’s mental health whilst he waited for formal assessment for suitability for the Structured Clinical Management programme. This possibly contributed to his death. On 1 April 2023 there was a significant delay in an ambulance attending upon Mr McCarlie following an emergency call. This delay was caused by an increased demand on the ambulance service. This delay contributed to Mr McCarlie’s death. The medical cause of death was: 1a Hanging 4 CIRCUMSTANCES OF THE DEATH 1st At around 23.23 on suspended by a ligature April 2023 Liam Paul McCarlie was found by paramedics Glasgow Coma Scale score of 3/15. His heart rhythm was asystole. . Mr McCarlie was not breathing, had no pulse and had a Earlier that evening he had exchanged text messages in which he had expressed an intention to take his own life. At around 17.52 his father and step-mother contacted the ambulance service. The call was assessed as requiring a 120 minute 90th centile response time. Paramedic led Double Crewed Ambulances had been allocated at 20.29 and 22.08 however both were stood down and reallocated to attend higher priority calls. At the time, the local ambulance service was experiencing a prolonged and significant increase in calls resulting in delays: a critical safety plan was in operation. A third paramedic led Double Crewed Ambulance was allocated at 22.50. That ambulance arrived at 23.11, i.e. 5 hours and 19 minutes after the initial call and therefore significantly outside of the 90th centile for a call of this kind. Had the ambulance service arrived within the required response time, it would have done so at a time when Mr McCarlie was still alive. The last recorded call from Mr McCarlie was at 19.26 (a call lasting 2 minutes). The last recorded text message was 1 sent by Mr McCarlie at 20.18. Death was confirmed at 00.33 on 2nd April 2023. In early February 2023 Mr McCarlie’s mental health deteriorated significantly. He was assessed by various mental health professionals, including a consultant psychiatrist. Mr McCarlie had previously attempted suicide in July 2021; following this he took anti- depressant medication until February or March 2023. On 15th February 2023 Mr McCarlie was identified as presenting with traits which were highly indicative of Emotionally Unstable Personality Disorder. He was referred to the Structured Clinical Management (“SCM”) programme. At the time of his death Mr McCarlie had not been formally assessed for suitability within the SCM programme. 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 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. – During the inquest I heard evidence from the Senior Quality Manager for Coroner Services at the East Midlands Ambulance Service NHS Trust (“EMAS”). She explained that some Integrated Care Boards had introduced a scheme whereby a mental health nurse would accompany a paramedic in a car and in appropriate cases would be dispatched to a patient for the purposes of meeting both their physical and mental health needs. The NHS Northamptonshire Integrated Care Board (“the Northamptonshire ICB”) did not adopt this scheme. Instead, the Northamptonshire ICB have introduced a mental health nurse located within the Emergency Operations Centres (“the EOC”) for the purpose of providing advice and, in appropriate cases, despatch from the EOC. I was told that members of EMAS have access to General Practitioner records held on SystmOne. EMAS does not have access to mental health records. In respect of Leicestershire, Lincolnshire and Nottinghamshire those records are held on a system called RiO. In respect of Northamptonshire and Derbyshire those records are held on SystmOne. I was told that there was no technical reason why EMAS staff (especially the mental health nurse located in the EOS) could not access a patient’s mental health records if held on SystmOne. There are such technical reasons why EMAS staff do not have access to RiO (an entirely different database). A data sharing agreement is likely to be needed as may a particular patient’s consent. I am concerned that notwithstanding the recognition of the desirability for specialist mental health input, those mental health professionals within the EOC do not presently have access to records which may have been produced by the community mental health team. That is notwithstanding that the principal database used by the provider of in Northamptonshire (the Northamptonshire community mental health Healthcare NHS Foundation Trust) is one to which EMAS does presently have access. Such information may be relevant to, for example, whether the patient has a history of suicidal ideation or attempts. That information may in turn be material to the triage and dispatch of ambulance resources. treatment 6 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. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th August 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: 1. The family of Liam McCarlie. 2. Northamptonshire Healthcare NHS Foundation Trust. 3. The Greens Norton Medical Practice. 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 24th June 2024 JONATHAN DIXEY 3
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.
East Midlands Ambulance Service NHS Trust Trust Headquarters 1 Horizon Place Nottingham Business Park Nottingham NH8 6PY Haylock House Kettering Parkway Venture Park Kettering NN15 6EY Tel: Web: northamptonshireicb.org.uk Private and Confidential Mr J Dixey Assistant Coroner The Guildhall St Giles’ Square Northampton NN1 1DE 15 August 2024 Dear Mr Dixey Letter to prevent future deaths Thank you for your letter dated 24th June 2024 regarding Mr Liam Paul McCarlie who sadly died on 2nd April 2023. We understand that you sent the letter to NHS Northamptonshire ICB (ICB) due to your concerns about the approach the ICB has taken alongside East Midlands Ambulance Service (EMAS) to provide mental health support to patients. In addition, you enquired about the possibility of Northamptonshire providers sharing mental health data with EMAS. Prior to your letter, the ICB and Northamptonshire Healthcare NHS Foundation Trust (NHFT) worked with EMAS to review the approach to providing mental health support to patients. In the latter part of 2023, we put in place a mental health crisis service to support the ambulance service to have access to MH practitioners within an hour of the call being received. This is run by NHFT, is in operation 24/7 and has received over 3,000 contacts in 12 months, with over 800 deployments to date. This is in addition to NHFT staff being located in the police control room. EMAS also continue to include mental health workers in their call centre, with a 24/7 service with 2 clinicians being on shift at any given time. To support the service, escalation is available from EMAS and NHFT to the mental health crisis line for advice and guidance. Your second question focussed on whether mental health data could be utilised prior to ambulance attendance to support decision making. Having reviewed the current approach with EMAS they confirm that call centre staff do not have access to patient clinical data beyond the information stated on the call. However, attending ambulance crews do have access to patient GP data whilst on- scene via a system called GP Connect. The ICB has been working closely with EMAS and NHFT to explore how best to share the entire patient record, including mental health data, with the ambulance service at every stage of the patient journey from initial call to attendance on-scene. EMAS have in the past attempted to deploy access to mental health records via other regional mental health Trusts who work off varying systems. This has proved complex with challenges identifying which systems to access dependent on the patient’s location within the region, and highlighted risks relating to multi system use within the Emergency Operations Centre (EOC). This has also proved challenging to enact in terms of time and resource to undertake licensing agreements, access, and training. As a result, access to these systems was not pursued further. EMAS are committed to working with the ICB and NHFT to identify the correct solution at pace, notwithstanding National work being undertaken in relation to alignment of systems that can be accessed by all. In July 2024 the National Ambulance Mental Health Group met, where it was identified that there would be varying risks in relation to regional providers undertaking a multi system approach. This was escalated to the National Ambulance Service Medical Directors Group as an area of concern. In the interim, whilst it has been explored and discussed, the possibility of access to mental health records via SystmOne for EMAS, the implications on the clinicians within EOC and the potential impact on patient care have led us to review whether this is the correct direction of travel. We are keen to implement a regional response to accessing mental health records within EOC to ensure consistency across the East Midlands. In the meantime, the response work from NHFT and the 24/7 mental health clinicians within EOC should mitigate against any risk in relation to correct response. Thank you for raising your concerns with the ICB. We continue to work alongside NHFT and EMAS to improve the service and care we provide to our patients and to learn from tragic circumstances such as those in your letter. Yours sincerely Chief Medical Officer Northamptonshire ICB Medical Director East Midlands Ambulance Service
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