Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0420, written 1 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2024 |
|---|---|
| Reference | 2024-0420 |
| Deceased | Stephen Lindsay |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| Category | Mental Health related deaths |
| Organisation named | Cumbria, Northumberland, Tyne and Wear NHS Foundation 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.
Kally Cheema LLB | Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
Case Ref: 11367656
1 August 2024
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: North East and North Cumbria Integrated Care
Board
CORONER
I am Robert Cohen, HM Assistant Coroner for Cumbria
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.
1
2
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 6 March 2024 I commenced an investigation into the death of Stephen LINDSAY. The
investigation concluded at the end of the inquest . The conclusion of the inquest was
Death by suicide.
3
1a Hanging
1b
1c
II
CIRCUMSTANCES OF THE DEATH
Mr Lindsay was 71 years old. He lived in Cockermouth, Cumbria. In October 2023 Mr
Lindsay was diagnosed with metastatic Oesophageal Cancer. He experienced a number
of complications associated with his diagnosis and was in pain.
4
In November 2023 Mr Lindsay reported to his GP that he felt overwhelmed. In January
2024 Mr Lindsay had a procedure at the Royal Victoria Infirmary, Newcastle. The RVI
Mental Health Team (operated under the aegis of Cumbria, Northumbria, Tyne and Wear
NHS Foundation Trust ('CNTW')) subsequently wrote to Mr Lindsay's GP noting concerns
about his mental health and suicidal ideation and noting that the efficacy of
antidepressant medication should be "monitored by services supporting Steven locally".
Mr Lindsay's GP referred him to the local Community Treatment Team run by CNTW. On
21st February 2021 that team responded: "This is a very sad situation and must be very
difficult for Stephen. I am sorry that CTT are not a service that can offer the interventions
that are needed at this stage. I am surprised that palliative care/McMillan team don't have
staff that can help Stephen understand the diagnosis and prognosis. I am sorry that I can't
be anymore help".
Mr Lindsay died on 28th February 2024. I concluded that his death was suicide.
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. –
5
(1) I am concerned that providing treatment for Mr Lindsay's mental health was passed
between several teams, with none of them being willing to accept that it fell within the
ambit of services they had been commissioned to provide. I am concerned that there is a
risk that in future cases mental health support will not be provided to those suffering from
terminal illness and that this may lead to other patients experiencing crisis and attempting
to end their lives. I consider that the lack of clarity as to the responsibility for providing
such care may cause further deaths.
(2)
(3)
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths and I believe you North
East and North Cumbria Integrated Care Board 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 26th September 2024. I, the coroner, may extend the period.
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 CNTW.
I am also under a duty to send the Chief Coroner a copy of your response.
8
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.
1 August 2024
9
Signature
Robert Cohen HM Assistant Coroner for
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.
Mr Robert Cohen HM Assistant Coroner for Cumbria Fairfield, Station Road, Cockermouth, Cumbria, CA13 9PT Dear Mr Cohen, NENC ICB Pemberton House Colima Avenue Sunderland SR5 3XB 19.09.24 Re Regulation 28 Report to Prevent Future Deaths - Mr Lindsay Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1st August 2024 concerning the death of Mr Lindsay on 28th February 2024. In advance of responding to the action raised in your Report, I would like to express my deep condolences to Mr Lindsay's family. The response from the North East and North Cumbria Integrated Care Board (NENC ICB) to the concern in your Report is as follows. Concern: I am concerned that providing treatment for Mr Lindsay's mental health was passed between several teams, with none of them being willing to accept that it fell within the ambit of services they had been commissioned to provide. I am concerned that there is a risk that in future cases mental health support will not be provided to those suffering from terminal illness and that this may lead to other patients experiencing crisis and attempting to end their lives. I consider that the lack of clarity as to the responsibility for providing such care may cause further deaths. The ICB have undertaken a review of Mr Lindsay's patient journey from the months prior to his diagnosis with metastatic Oesophageal Cancer up until his date of death. Working with the organisations involved each team has completed a review of their care and treatment and reflected on the patient's pathway. As a result, a few immediate actions were identified and are currently being implemented. These are as follows: • Cumbria, Northumberland, Tyne and Wear NHS FT (CNTWFT) are raising awareness with their teams of the Marie Curie helpline for people living with terminal illness as well as educating teams on the Macmillan service offer. • North Cumbria Integrated Care NHS Trust (NCIC) have provided further training to the palliative care team to help better support conversations with patients, who may have risk issues, how to assess them and to secure the right level of care. The Trust are also reviewing their draft Mental Health Strategy, this is to ensure it reflects and highlights that those patients presenting with a long-term condition are likely to have a higher risk of death by suicide. The strategy will also clearly outline the role and responsibilities of the CNTWFT mental health teams and the necessity to share assessments and safety plans with relevant parties. To further address your concern, the ICB will also be holding a reflective learning event with those involved in Mr Lindsay's care and treatment. This will enable the teams to reflect, identify and explore further opportunities to improve patients experience of care and to ensure that there are no unforeseen barriers in ensuring that any patient suffering a terminal illness receives seamless, responsive and supportive care. We would be happy to share the outcome of this event with Mr Lindsay's family and yourself. Thank you for bringing this important patient safety concern to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, Chief Nurse AHP People Officer North East and North Cumbria Integrated Care Board
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