Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0459, written 19 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 | 19 Aug 2024 |
|---|---|
| Reference | 2024-0459 |
| Deceased | Juliette Sewell |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Birmingham and Solihull Mental Health NHS Foudation Trust
CORONER
I am Mr Adam Hodson, 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 23 April 2024 I commenced an investigation into the death of Juliette Kirsty SEWELL. The
investigation concluded at the end of the inquest. The conclusion of the inquest was; Suicide
CIRCUMSTANCES OF THE DEATH
In the afternoon of 16/02/2024, Juliette was discovered unresponsive in
by a
family friend, surrounded by multiple empty packets of medications, and was subsequently
confirmed deceased at 13:43. Post-mortem investigations indicated she had died from a
fatal overdose. Juliette had been missing since the evening of 14/02/2024 when she left
home following difficulties in her personal life and was last seen alive by a friend at around
22:00 on 14/02/2024. Juliette was seen crying on the porch of her friend’s home on
Fallowfield Road before heading in the direction of
mental health illness since 2010 and had been under the care of both her GP and her local
mental health team. At the time of her death, Juliette had been awaiting a follow-up
appointment with the mental health team since January 2023 which had been delayed due
to staffing shortages, but it is unlikely that her death could have been prevented.
. She had a history of
Following a post mortem, the medical cause of death was determined to be:
and
toxicity
1a
1b
1c
II Presence of
CORONER’S CONCERNS
,
,
,
,
and
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. –
1. Following Juliette's death, a Structured Judgement Review ("SJR") was carried out which
identified steps that have been taken. However, the SJR confirmed that a review of Rio
records was being undertaken of those who have not been seen in over 12 months with
actions to be identified, and that clinical stratification of current caseload is ongoing. I
understand that a review or audit of this process is being scheduled to take place at some
point in October 2024 (date unknown).
2. Upon conclusion of the inquest, I am Functus Officio meaning that my powers cease and I
will have no way of checking if the recommended actions have been completed. In the
circumstances, where action to be taken is outstanding and when a specific review date
has not been scheduled, I am concerned that there is a risk of future deaths occurring.
3. The deadline for a response under this Report should coincide with the Trust's planned
review/audit in October, therefore I am hopeful that the Trust will be able to respond swiftly
thereafter, and hopefully will be able to confirm that positive action that has been taken and
whether any further work is necessary.
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
14/10/2024. I, the Coroner, may extend the period upon request.
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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:
, Sister
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I have also sent it to the Medical Examiner, ICS, NHS England, CQC, 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.
19 August 2024
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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, Assistant Coroner, Birmingham and Solihull Areas, BIRMINGHAM B4 6BJ BY EMAIL ONLY TO: Our Ref: Your Ref: Date: 10 October 2024 Dear Mr Hodson Re: Prevention of Future deaths Juliette Sewell Thank you for your Prevention of Future Death Report dated 19 August 2023. I would like to take this opportunity to offer my sincere condolences to Juliette’s family for their loss and also offer my assurances that we have carefully reviewed her case and made improvements. In relation to the outstanding action you have highlighted. I can confirm that in order to provide you with assurances by the date of your PFD response, we have brought forward the necessary steps to ensure the completion of the action earlier than anticipated. I can confirm that there continues to be an ongoing review of our Electronic Patient Record (EPR) RiO records for service users who have not been seen by any clinician within the team for over 12 months as part of ongoing monitoring. As of September 2024, there are 553 service users who have not had contact with Lyndon CMHT in over a year, which is 21.14% of the total caseload. Of the 553 service users, 36.99% (204) have been offered at least one appointment in the last year by the team but did not attend (DNA). The caseload stratification work described at the inquest continues to develop, to date, 1028 desktop reviews have been completed. Of this number, 436 have since had contact with the CMHT and a further 110 have an appointment booked on the system. Lyndon CMHT books appointments up to five weeks ahead, so the remaining 482 service users will be booked in when new appointment slots become available. The 482 patients are existing patients of the CMHT, they have had appointments with the CMHT and have Care Support Plans in place. Further appointments are being made with them to review the next stage in their ongoing treatment and care and consider whether their needs can be met by the Neighbourhood Mental Health Team. Patients are informed at their appointment by the relevant clinician that they will be offered a further appointment, in the meantime if the need arises, they are advised to contact the CMHT duty worker or Chair: │ Chief Executive: │ Website: www.bsmhft.nhs.uk Customer Relations: Mon–Fri, 8am–6pm │ Tel: │ Email: out of hours numbers. This contingency plan is also included in the care support plans that patients receive following their appointment. Where patients require more urgent appointments, this is discussed with the relevant doctor to make arrangements for the patient to be seen by a duty worker or by a doctor in an urgent outpatient slot. The team also review service user needs by way of MDTs for those patients who have been waiting for an extended period time. STR workers will also go out and visit service users if we have not been able to reach them on the phone. There are process to ensure clinical contact with patients to check on their mental health and wellbeing, and if necessary any urgent need for an appointment would be expedited with an appointment being booked in the next available slot or an urgent appointment to be arranged. Alongside this work, the team are also implementing a new system to improve the booking of out-patient appointments and development of a report that will easily identify those who are approaching the scheduled date of their next appointment with the team. This work is underway and significant changes have already been made to the processes for booking of appointments, which has seen a reduction in our DNA rates. The development of the report relies upon changes being made to RiO. These changes are due to be added to the ‘test’ system by 27th September 2024 and will go ‘live’ from 31st October 2024. Once data has been input into RiO the report can be finalised and launched. All other systems are in place to support the report from the ‘go live’ date, and this will strengthen the clinical oversight we have of the caseload. Whilst waiting for the above work to be implemented, there is scrutiny of the waiting lists by the Associate Director, Head of Nursing, Clinical Director, and Clinical Services Manager fortnightly. The Clinical Services Manager also scrutinises the waiting lists and those who have not been seen for over 12 months at a monthly meeting with the Hub Manager and Business Support Services Manager. The following processes are continuing: • The list of those who are open but not seen for over 12 months is available via Insight reports. This is scrutinised on a regular basis by the Business Support Services Manager and their team, who then highlight these cases to a senior clinician (i.e. Psychiatrist, Hub Manager, Clinical Lead) within the team so that they can determine the management plan and when the service user needs to be seen. • Continue with current meetings to scrutinise waiting lists and overall caseload. • Hub Manager to provide Clinical Services Manager with a weekly position update of progress being made for those who have not been seen for over 12 months, and to escalate any barriers that may be hindering this. • Caseload stratification work to continue, with monthly updates to be sent to Clinical Services Manager detailing how many have been completed and the outcome of these (e.g. seen by team, discharged to GP, transferred, etc). We hope that we have been able to offer reassurances that as a Trust we are committed to improving services for our patients and ensuring that improvements are made as soon as possible. If we can provide any further information, please do not hesitate to contact us. Yours sincerely Chief Executive BSMHFT 2
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