Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0498, written 18 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Sep 2024 |
|---|---|
| Reference | 2024-0498 |
| Deceased | Helen Kerr |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive Officer Surrey County Council 2. Chief Constable Surrey Police 3. Chief Executive Surrey and Borders Partnership 1 CORONER I am Caroline Topping, assistant coroner, for the coroner area of Surrey 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 24th April 2023 an investigation into the death of Helen Jane Kerr was commenced. The investigation concluded at the end of the inquest on 7th June 2024. Helen Kerr died by hanging. The conclusion as to death was a narrative conclusion as follows: Helen Kerr went to live at in a refuge in Woking on the 2nd February 2023. She had a history of drug and alcohol abuse and was referred to I access. Her mental health deteriorated, and she developed psychosis. On the 1st March 2023 she was assessed at I access and a plan for a referral to the community health team was devised. The referral was not made because of pressure of work. On the 13th March 2023 her support worker was so concerned by her mental health that she called an ambulance and Helen was taken to St Peter’s Hospital. She was seen by a nurse from the liaison psychiatry team. No collateral information was sought and the full description of her presentation from the paramedics was not seen. She was assessed as not requiring a referral to the community mental health team despite showing signs of paranoid delusions. She was discharged. Her support workers made repeated attempts to obtain mental health care for Helen contacting the single point of access, I access, the community mental health and the CRISIS line. Helen’s case was not discussed with a psychiatrist and her support workers were not contacted for information by any of these organisations. On the 31st March 2023 Helen attended Surrey Police station in an extremely paranoid state and then went to St Peter’s Hospital seeking an admission. She was partially assessed by liaison psychiatric nurses and offered a home treatment team assessment. She declined and was discharged by the team without collateral information being sought or the advice of an on-call psychiatrist. She needed to be admitted to hospital for a diagnosis and treatment of her mental health condition. 1 She was discharged from hospital on the 2nd April 2023 and returned to the refuge. She was found dead on the morning of the 3rd April 2023 having self-ligatured. Her condition was amenable to treatment with anti-psychotic medication. The death was avoidable with appropriate treatment. She intended to take her own life. She died by suicide. The death was contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH See the details set out in the narrative conclusion. In addition: Prior to being placed in the refuge on the 2nd February 2023 Ms Kerr was charged with carrying a bladed article when she surrendered to bail. She told the police that she was carrying a knife for her own protection. This was known to Surrey Police and mental health services by March 2023. On the 13th March 2023 paramedics contacted the police for assistance at the refuge concerned because she was carrying a nail file for her own protection. When she attended Surrey Police station on Friday the 31st March 2023 she did so concerned for her own safety. She was extremely paranoid but was assessed not to warrant s136 detention. She left the police station saying she was going to hospital. A SCARF was written but could not be lodged before the end of the working day on the 31 st March 2023. As a result, it was not processed until Monday the 3rd April 2023, after her death, because SCARF’s are processed during working hours. The expert gave evidence was that she would have been very worried if she was told Ms Kerr was carrying a knife because she was having paranoid delusions that she needed to protect herself and her family. Some of Ms Kerr’s paranoid delusions related to concerns about the actions refuge workers. The refuge was not contacted by the police on the 31st March 2023. The court was told that GDPR prevented the police from sharing the information about Ms Kerr with the refuge. 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. Following the conclusion of the Inquest a considerable amount of evidence has been provided by Surrey and Borders Partnership in relation to changes in procedures in relation to processing of referrals into their services. Referrals into the Single Point of Access can now be made by voluntary agencies and new protocols require more senior oversight of triaging decisions and recording of collateral information from referrers. In addition, a review of the SCARF process is being undertaken but has not yet concluded. However, I remain concerned about a number of matters: The MATTERS OF CONCERN are as follows. – (1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly 2 to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment. Despite the evidence that significant changes are being put in place the efficacy of these changes has not yet been evidenced. (2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk. (3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public. (4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] 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 12th November 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mrs Kerr’s Family St Peter’s Hospital The Refuge (details redacted) I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 18th September 2024 [SIGNED BY CORONER] Caroline Topping 9 3 4
3 responses 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.
Ms C Topping HM Coroner’s Court Station Approach Woking Surrey GU22 7AP Woodhatch Place 11 Cockshot Hill Woodhatch Reigate RH2 8EF 30 October 2024 Re: Kerr 28 Report - Action to Prevent Future Deaths – Helen Jane Kerr Dear Assistant Coroner Topping, Further to the issuing of a Prevention of Future Deaths Report on 18 September 2024, please find below Surrey County Council’s (SCC) response. At the outset, SCC wishes to pass on our condolences to the Kerr family. As advised by coroner officer Sarah Church, you were seeking a response from SCC in respect of question 3 of the points of concern, namely in relation to information sharing and the SCARF process. The Scarf Process is not designed to be used as an emergency referral out of hours. There is a clear, well known and well used process for officers, in that they must contact the Emergency Duty Team outside hours, if they need urgent social care intervention. The EDT has a single number that is published on the SCC website https://www.surreycc.gov.uk/adults/care-and- support/contact . This has not changed for many years. In terms of the Police the relevant numbers are included within all of the Mental Health briefing products (briefing slides, routine orders) and the force Mental Health guide which is available via officer’s mobile devices and their intranet hub. The number is also included within all of their training products relating to s136. For this reason, there is no mechanism, and no need for SCARF to be shared outside of office hours as any information can be passed between the officers at the scene and social services in real time. This would not rely on a SCARF being completed in an emergency situation. SCARF should only be used where the situation has been left in a way that it is suitable for the sharing to be delayed until the next day or over the weekend. 1 Yours sincerely, Director for Mental Health, EDT and Prisons Adults Wellbeing and Health Partnerships 2
Chief Constable 11 November 2024 Dear Mr Travers, In response to the Regulation 28 notice following the inquest of Ms Helen Kerr, I write to you to provide updates to each matter of concern. The matters of concern, relevant to Surrey Police, are as follows. – 2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk. As a point of learning, all officers are being reminded to ensure that research is undertaken as soon as practicable when dealing with members of the public, including asking the Force Control Room to do so on their behalf when it is impracticable to do so themselves. In this instance, by asking the Force Control Room, this would have enabled an alternative Surrey Police employee to assess previous information held on Surrey Police systems whilst they were engaging with Ms Kerr. This message will be conveyed by force emails and a reminder on the daily briefing to response officers. We fully accept that this research should have been conducted in order to inform the officer’s decision making. This incident was reviewed as part of the inquest and the officer who saw Ms Kerr explained her rationale as to why she did not use her section 136 powers under the Mental Health Act. The officer did undertake research following Ms Kerr’s departure from the police station and submitted a SCARF (see point 3 below). This decision, which was also based on the research, was supported by a supervisor at the time of the incident and reviewed by the force mental health lead as part of the inquest proceedings. Surrey Police, PO Box 101, Guildford, Surrey, GU1 9PE | surrey.police.uk Although Ms Kerr did previously carry a nail file for her own protection, the officer would have required grounds to search Ms Kerr. Although some forces are operating a pilot allowing them to search a person with a previous conviction of a weapons offence, who has a court order made against them upon conviction, Surrey is not a pilot force, and Ms Kerr was in any case highly unlikely to have met the required threshold for such an order. Therefore, an officer would rely on the powers conveyed in Section 1 of the Police and Criminal Evidence Act to conduct a search, but in order to do so, they would need to have reasonable grounds to suspect that they will find something prohibited (i.e. a weapon). At the relevant time, the officer did not have this suspicion. There was no information at the time to suggest Ms Kerr was a risk to either herself or the public at large. (3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public. The SCARF is not intended as a crisis management tool, nor is it intended to convey imminent unmitigated risk, which is laid out in the SCARF policy which all officers and staff can access. The SCARF is intended to pass safeguarding information where it has been deemed that there is no requirement for imminent action. In simple terms, Police have left the person safe in the immediate time frame and it is normal and appropriate for the SCARF to be assessed in a timely manner, (but not immediately), and to be screened and assessed by professionals. Although police submit SCARFs 24/7 to the PSPA (Police Single Point of Access), a review and sharing information out of hours by the PSPA is not completed. The PSPA offers coverage 0900- 1700hours Monday to Friday. If we share SCARF outside of these hours, they would only wait in our partners (adult’s or children’s services) mailboxes until business hours. Surrey Police PSPA used to work weekends until recently, but this was removed because referrals processed were not seen by other agencies. There are numerous things that officers can do in terms of informing our partners about more imminent risk. The primary one is the Emergency Duty Team (EDT) – this process is long established for response officers. This is person-to-person communication between agencies, where agreements can be made and issues escalated. Likewise, there are other methods, such as the professionals / crisis line / Accident and Emergency departments etc. All of these are 24/7 where ‘real time’ concerns can be discussed and safety plans formulated. However, although information can be shared via these methods, practically they are designed mainly for organising immediate out of hours response. In these circumstances, those involving Ms Kerr, officers decided that there was nothing that required this level of immediate response, nor the use of section 136 powers which was heard at the inquest. As a result, the SCARF would normally be during the the correct method of information sharing as was the evidence submitted by inquest. Surrey Police, PO Box 101, Guildford, Surrey, GU1 9PE | surrey.police.uk (4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger. Information sharing protocols are in place with statutory partners. The refuge is not a statutory partner, so with regard to the sharing of SCARF, there would be no existing process that would include them in Surrey Police’s safeguarding information sharing protocols. Adult Social Care would be responsible and facilitate any onward information sharing if appropriate, based on a multi-agency assessment. I hope that this response is sufficient. Please advise me if I can be of further assistance. Yours sincerely, Chief Constable Surrey Police, PO Box 101, Guildford, Surrey, GU1 9PE | surrey.police.uk
11 November 2024 Private and Confidential Ms Caroline Topping Assistant Coroner for Surrey Sent by email: Chief Executive Chief Executive’s Office Surrey and Borders Partnership NHS Foundation Trust 18 Mole Business Park Randall’s Road Leatherhead KT22 7AD Dear Ms Topping Helen Kerr (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 18 September 2024, in relation to the inquest touching the death of Helen Kerr. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues from the relevant divisions. In the PFD report, you highlighted that a considerable amount of evidence has been provided by the Trust of the changes around processing referrals into our services. In particular, the PFD report notes that referrals into the Single Point of Access (“SPA”) can now be made by voluntary agencies and new protocols require more senior oversight of triaging decisions and recording of collateral information from referrers. In addition to the above improvements, the Trust website was updated to provide detail to external professionals on the different routes for emergency, urgent and routine referrals. There is now greater collaboration with family and referrers, supported by changes to the SBAR (a structured tool for communicating and sharing information which requires recording of the Situation, Background, Assessment and Recommendation) to now include carer/family views which are factored into decision making. The implementation of the new SPA procedures is currently subject to testing in line with our quality improvement approach. The aim of this is to provide assurance that the new processes are applied consistently and are embedded. We have introduced a quality control process within SPA and the ongoing testing and review will allow us to identify other ways in which the service can be optimised As part of this work, we are taking additional steps to enhance the out of hours offer. Page 1 of 3 During the inquest, the Trust also provided written evidence of improvements that had been implemented in the Psychiatric Liaison Service (“PLS”), particularly in relation to ensuring that collateral information is obtained. The PLS Standard Operational Policy (“SOP”) has now been updated to reflect these changes. This document was ratified and disseminated to all PLS teams in September 2024. The improvements include an emphasis on identifying relevant sources of collateral information and the process that should be followed when a clinician is unable to access relevant collateral information. It outlines that, in these circumstances, consideration should be given to delaying discharge to allow further attempts to obtain collateral and formulate a safe discharge plan. Further changes to the SOP include greater emphasis on staff utilising support of other practitioners when lone working to assist decision making. A random dip audit of assessments across our five PLS services in September 2024 confirms a trajectory of improvement in that collateral information was sought in 90% of cases, as compared to 80% when the same audit was conducted in June 2024. Further progress has been made in the development a digital solution which will more robustly support the obtaining and recording of collateral information. A collateral history section has been added to the new PLS assessment template as a mandatory field. There is also a section where a reason must be provided if collateral information has not been obtained. The roll out of the new assessment template has been expedited to the Psychiatric Liaison Services and is currently being tested in two of our PLS services as part of our quality improvement approach and in order to trial clinical effectiveness. Full roll out is anticipated to be completed by the end of 2024. Alongside the changes to the SOP and the digital assessment template, a case formulation and presentation outlining the learning from Ms Kerr’s inquest has been developed by one of the divisional Nurse Consultants. This provides a forum for reflection and learning to ensure that clinicians understand the factors that were relevant to Ms Kerr’s sad death, and their responsibilities in implementing the improvements that the Trust has made. The case formulation supports the translation of the learning into changes in practice and will have been presented to all PLS teams by the end of November 2024. Further learning is reflected in the production of training which has been developed and rolled out across our i-access services. This focuses on recognising signs and symptoms of psychosis and the importance of a timely referral to mental health services for assessment. To date, 86% of relevant staff have viewed this training and it is planned that the remaining staff (who have been unable to do so due to absence from work) will have viewed this by 15 November 2024. The PFD Report also outlines a concern that the Single Combined Assessment of Risk Form, known as a SCARF, does not enable information sharing between organisations out of hours. The purpose of a SCARF is to help police officers to record and raise safeguarding concerns and observations about the needs, vulnerabilities and risk issues relating to those who come into contact with the police. A SCARF is not designed to be used to access crisis support or obtain emergency assistance. If the police have concerns which require urgent attention or advice, there is a dedicated Professionals Line which operates 365 days a year, 24 hours a day. The Professionals Line number is published on the Trust’s website and can also be accessed by any healthcare professional, or voluntary or statutory agency where an urgent discussion is required. This allows professionals, including from the police or social services, to share or request critical information in an immediate timeframe to help inform decisions about people they have come into contact with. Furthermore, the Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s may use. This also operates 365 days a year, 24 hours a day. The SCARF process is therefore only a way of sharing information between organisations and, where there is an urgent need, the crisis referral pathway should be used. Page 2 of 3 The other matters within the PFD Report relate solely to Surrey Police and I will therefore allow that organisation to address those issues directly. On behalf of the Trust, I would like to offer our sincere condolences to Ms Kerr’s family for their loss. Yours sincerely, Chief Executive Page 3 of 3
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