Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0487, written 15 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jul 2024 |
|---|---|
| Reference | 2024-0487 |
| Deceased | Phephisa Mabuza |
| Coroner | Patricia Harding |
| Coroner area | Central and South East Kent |
| Category | Mental Health related deaths · Community health care and emergency services related deaths |
| Organisation named | Essex Partnership University 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.
Central and South East Kent Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Email: Telephone: Date: 15 July 2024 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST 1. CORONER I am Patricia Harding acting senior coroner for Central and South East Kent 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 21 March 2023 I commenced an investigation into the death of Phephisa Siphelele MABUZA. The investigation concluded at the end of an inquest held on 29th April 2024. The conclusion of the inquest was: Narrative- Phephisa Mabusa was found at the base of Dover on the morning of 14th March 2023 having died from injuries consistent with a fall from height. He was last known to be alive at 14.18 on the afternoon of 13th March 2023 when he was sighted walking alone toward the area where he was later found. He had travelled from South End on Sea to Dover by rail and had withdrawn cash on route. He had not taken olanzapine prescribed for psychosis for a number of months and was hearing voices in the days before his death but had not voiced any intention to take his own life. The evidence does not disclose how he fell or his intention at the time, but his death likely occurred on 13th March 2023 The medical cause of death was established following a post mortem to be from 1a Multiple Injuries 4. CIRCUMSTANCES OF THE DEATH Phephisa Mabusa was diagnosed with psychotic disorder. He had been admitted to hospital as a result on a number of previous occasions, the last in July 2022 following which he was prescribed olanzapine in the community which he continued to take until the end of October 2022 when he moved out of the supported accommodation where he had been living and moved to Nottingham with his girlfriend. Phephisa had been under the care of the Essex mental health team but was discharged from their service because of his move out of the county. His care co-ordinator advised him to register with a new general practitioner so his olanzapine prescription could continue and so that the mental health team could advise the new General practitioner of Phephisa's contact with the Essex Mental Health Services. Whilst he registered with a general practitioner, he did not request a prescription. He returned to Essex on 4th November 2022 and although the supported accommodation where he had been staying was available to him, he decided together with his mother that he should get a job and get his own place rather than live in supported accommodation. He moved in with his mother. Phephisa registered with a general practitioner in the following days but did not ask for his olanzapine prescription to be restarted. His mother did not become aware that he had not been taking his medication until February 2023 when she noticed that symptoms her son started to have when in the early stages of psychosis appeared to have returned. She called his general practitioner on 3rd March 2023 but was not available when the GP called back. She made further attempts to contact his general practitioner on 7th March 2023, but on this occasion did not receive a response and therefore on 10th March 2023 rang the 111 service where she spoke to a mental health nurse who conducted a telephone triage speaking to both Phephisa and his mother. The mental health nurse’s conversation with Phephisa was very brief because Phephisa reported being tired. The mental health nurse contacted the first response team to make a face to face appointment with Phephisa and also requested his general practitioner reconsider prescribing olanzapine again. A prescription was sent electronically to the pharmacy, but the spine system disconnected and the prescription request would not go through. The prescription was therefore not available for sorry, the prescription was not therefore available for collection on 13th March 2024, when Phephisa's mother went to collect it. She did not see her son again and reported him missing when she returned from work the following day. Phephisa's death had been reported to Kent Police 10 minutes before he was reported missing to Essex Police. 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. – (1) Essex Partnership University NHS Foundation Trust Crisis Response Service follows the UK Mental Health Triage scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. The scale is embedded within the 111 Triage form utilised by clinicians in their clinical decision making following a triage. The Trust has departed from the national guidance for category D presentations such that the local guidance has been amended to reflect a 7 day response when the national guidance states 72 hours (2) Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours- same day response@ and do not reflect the scale on the 111 Triage form or the national guidance. I delayed issuing this report so that the Trust could inform me of the current position and whether any remedial action had been taken. A memo has been sent to all staff to notify them that the operational policy has been wrongly coded but a decision had not yet been taken as to whether and how the Trust intended to move forward in respect of the departure from the national guidance 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Essex Partnership University NHS Foundation Trust 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, namely by 9th September 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 the legal representatives of the family I have also sent it to the senior coroner for Essex 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. 15 July 2024 Signature Patricia Harding Senior Coroner for Central and South East Kent
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.
4th September 2024
Private and Confidential - By Email Only
Ms Patricia Harding
Coroner’s Court
Oakwood House
Oakwood Park
Maidstone
ME16 8AE
Dear Ms Harding,
Phephisa Siphelele Mabuza (RIP)
Chief Executive Office
The Lodge
Lodge Approach
Wickford
SS11 7XX
I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013,
dated 15th July 2024 in respect of the above, which was issued following the inquest into the sad death of
Phephisa Mabuza.
I would like to begin by extending my deepest condolences to Phephisa Mabuza’s family. The Trust
sympathises with their very sad loss.
The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I
will now respond in full to these concerns in the hope that this provides both yourself and Phephisa
Mabuza’s family with comprehensive assurance of changes that have been made at the Trust to address the
concerns you have raised.
I should say at this point, that in considering our replies we have again reviewed / confirmed the assurances
previously provided to your Court. Each concern however has been looked at afresh, and has been cascaded
to team leads.
Concern a)
“Essex Partnership University NHS Foundation Trust Crisis Response Service follows the UK Mental Health
Triage scale in classifying the urgency and service response requirements of clinical presentations at the point
of contact. The scale is embedded within the 111 Triage form utilised by clinicians in their clinical decision
making following a triage.
The Trust has departed from the national guidance for category D presentations such that the local guidance
has been amended to reflect a 7 day response when the national guidance states 72 hours”
Response:
The Crisis Response Services (CRS) across the Trust follow the UK Mental Health Triage Scale in classifying the
urgency and service response requirements of clinical presentations at the point of contact. This form of
triage scale is only used within the Crisis Response team. Whilst this guidance is not produced by NICE, it is
the accepted guideline for use across the country for those organisations who offer this service.
Since CRS was started at the Trust in 2020, the scale is embedded with our 111 Triage form and offers
guidance to clinicians in their clinical decision-making following a triage, however Category D has been
amended to reflect 7 days. During our investigations, the Trust was unable identify exactly why the decision
was taken, however it appears to have been done to align with our community services in their operational
frameworks, as the Trust embedded CRS into its services. In light of this, the senior management in the CRS
and the Business Partners, have met to take forward this point. We now have clear clinical rationale
frameworks, consistency, and appropriate and safe time frames for our patients coming through CRS.
Additionally work is underway in order to ensure Trust Policies align with national standards as required.
Concern b)
“Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the
Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours- same day
response and do not reflect the scale on the 111 Triage form or the national guidance”.
Response:
The existing Standard Operational Policy in place is only for use by the Crisis Response Services across the
Trust. It is acknowledged that the triage response times on Triage Codes D and E on the appendix were
incorrectly stated as “Within 24 hours – Same Day” response, and do not reflect the scale on the form in use
on the clinical system. This was owing to a typing error when the policy was completed, and that was
unfortunately not picked up before the document went live. The Trust sincerely apologises for missing this,
and the confusion it caused to both the Court and to the family.
The Standard Operational Policy has been reviewed and the identified errors rectified. A memo has been
sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale in
informing their clinical judgment in the decision making process. This has also been shared with the leads
covering the other CRS teams.
I hope that I have provided reassurances around the steps that we have taken to address the issues of
concern contained within your report. We appreciate that there is an acute need to embed and effect
change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of
keeping patents safe and delivering therapeutic care.
Please do let me know if you require any further information at this stage, including copies of any of the
documents referred to above.
We trust that your Court will share, as standard, a copy of this reply with Phephisa Mabuza’s family
Yours sincerel
Chief Executive
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