Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0514, written 26 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 | 26 Sep 2024 |
|---|---|
| Reference | 2024-0514 |
| Deceased | Charne Petit |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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. Chief Executive Surrey and Borders Partnership Trust 2. Chair NHS England 1 CORONER Caroline Topping, H.M Assistant Coroner for 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 30th May 2023 an inquest was opened into the death of Charne Nikita Petit. The inquest was concluded on 30th July 2024. The medical cause of death was: 1a. Suspension. The narrative conclusion was that: Charne Petit suffered from psychotic delusions which she found extremely distressing. From 2019 to 2022 she was treated by the early intervention in psychosis team. Thereafter her care was transferred to the community mental health team. Her symptoms and mood fluctuated, in addition, on occasions, non- compliance with anti-psychotic medication and use of illicit drugs triggered relapses in her mental health. On the 26th March 2023 she suffered a psychotic breakdown and was assessed under the Mental Health Act and found to meet the requirements for detention under s2. No mental health bed was available. She was nursed one to one in the Royal Surrey County Hospital by nurses from the psychiatric liaison team. She was re-started on aripiprazole and her mood stabilized. She was discharged to the home treatment team on the 31st March 2023 without an assessment followed by medical treatment in a mental health hospital. On the 24th April she was seen by her care coordinator and reported intrusive psychotic delusions and struggling to manage her emotions. On the 25th April 2023 she represented to Royal Surrey County Hospital having abused drugs. She was assessed not to require a mental health assessment and discharged. On the 12th May 2023 she killed herself by suspending herself effective treatment of her psychosis. The lack of a mental health bed after she was assessed as detainable under s2 more than minimally contributed to the death. . The death was preventable with more She died by Suicide 4 CIRCUMSTANCES OF THE DEATH See the details set out in the narrative conclusion. In addition: 1 Ms Petit was reviewed in hospital on the 29th March 2023 by a consultant from the liaison psychiatry team. Her presentation had improved since admission and in his opinion, so long as she continued to improve, she could be discharged to the home treatment team and that this was the least restrictive option. The effect of the discharge on the 31st March 2023 was that Ms Petit was not admitted to a mental health hospital under section 2 of the Mental Health Act 1983 and was therefore discharged without having been assessed comprehensively in a mental health hospital. 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. – (1) Evidence given by the court appointed expert consultant psychiatrist was that Ms Petit was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed. This is what a s2 admission is designed to effect. The lack of a bed in a mental health hospital denied Ms Petit this opportunity for optimal treatment. (2) The Court heard that owing to a shortage of mental health beds patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed, because they cannot be placed under section unless a mental health bed is available. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Chief Coroner Ms Petit’s Family Hopewell House Royal Surrey County Hospital I have also sent it to the Royal College of Psychiatrists and Surrey County Council who may find it useful or of interest. 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. [DATE]26th September 2024 [SIGNED BY CORONER] Caroline Topping 9 3
2 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 Caroline Topping
HM Assistant Coroner for Surrey
Surrey HM Coroner’s Court
Station Approach
Woking
GU22 7AP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
21 November 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Charne Nikita Petit who
died on 12 May 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26
September 2024 concerning the death of Charne Nikita Petit on 12 May 2023, sent to
the Chair of NHS England. I am responding on behalf of the organisation in my
capacity as National Medical Director but would like to assure you that the Chair has
also been sighted on this response and has reviewed your Report. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Charne’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Charne’s care have
been listened to and reflected upon.
Your Report raises concerns over a national shortage of mental health beds. The
number of mental health beds required to support a local population is dependent on
both local mental health need and the effectiveness of the whole local mental health
system in providing timely access to care and supporting people to stay well in the
community, therefore reducing the likelihood of an admission being necessary.
In some local areas there is a need for more beds. This is being addressed in part
through investment in new units and additionally as part of a whole system approach.
This was supported by the NHS Long Term Plan (LTP), which saw an additional
£2.3bn funding invested in mental health services from 2019/20 – 2023/24, around
£1.3bn of which was for adult community, crisis and acute mental health services to
help people get quicker access to the care they need and prevent avoidable
deterioration and hospital admission. NHS England’s 2024/25 priorities and
operational planning guidance continues this focus on improving patient flow as a key
priority – with systems directed to reduce the average length of stay in adult acute
mental health wards and in order to deliver more timely access to local beds.
To address the wider system issues that impact on health services, a further £1.6bn
has been made available via the better care fund from 2023-25. This funding can be
used to support mental health inpatient services as well as the wider system which
should help to reduce pressures on local inpatient services so that those who need to
access beds can do so quickly and locally.
This is being supplemented by a further £42m recurrent investment from 2024/25 for
all ICBs in the country to recommission inpatient care in line with local models that
provide the best evidence of therapeutic support
It is appropriate that Surrey and Borders Partnership Trust respond to your first
concern regarding Charne not being properly medicalised or observed, as well as their
inpatient mental health provision. I note that your Report was also addressed to the
Trust and NHS England has asked to be sighted on their response to the Coroner.
We have also engaged with Surrey Heartlands Integrated Care System, who we are
aware are working with and monitoring improvements with the provider.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors, and
other clinical and quality colleagues from across the regions. This ensures that key
learnings and insights around events, such as the sad death of Charne, are shared
across the NHS at both a national and regional level and helps us to pay close
attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
21 November 2024 Private and Confidential Ms Caroline Topping 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 Charne Petit (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 26 September 2024, in relation to the inquest touching upon the death of Charne Petit. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues. In the PFD report, you raise concerns that Ms Petit was not adequately medicalised while she remained at Royal Surrey County Hospital (RSCH) awaiting an inpatient psychiatric bed. We recognise the demand for mental health inpatient beds outweighs availability and that this places significant pressure on the health and care system, not only in Surrey, but also nationally. The King’s Fund outlines: “With the exception of the Covid-19 period, when many beds were closed due to infection control, the current numbers of mental health beds (17,836) are at their lowest level since data collection began in 2010/11. Bed occupancy has remained consistently over the recommended level of 85% – the point at which quality of care is at risk of being compromised. As a consequence, people who need to be admitted can face considerable delays in accident and emergency (A&E) while they wait for an available bed, or may be cared for in inappropriate environments, such as being admitted to a ward in an acute trust.”1. At a national level, this lack of bed availability is a matter for the Secretary of State for Health to address. Nonetheless, the Trust and our staff work to provide appropriate treatment in the context of the impact of bed shortages to those who require inpatient treatment. In response to the national shortage of mental health acute beds, the Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice. This is an NHS England framework which provides a consistent approach to managing demand across the health and social care system and a procedure for managing surges in demand for inpatient mental health beds. OPEL bed meetings are convened every morning by locality 1 1 https://www.kingsfund.org.uk/insight-and-analysis/long-reads/mental-health-360-acute-mental-health-care- adults, 21 February 2024 Page 1 of 3 Associate Directors to discuss any actions that can be undertaken to increase bed capacity as well support people awaiting hospital admission, including those waiting in acute hospitals. If there are no beds available in the Trust, external options are considered including private sector providers. The use of private beds is dependent on availability, whether the person and their family are willing to access beds outside of Surrey, and acceptance of the referral by the private provider. Another option utilised is that the Trust will approach neighbouring Trusts to see if they can assist. Trusts have their own bed resource challenges however and there is often no scope to assist in this way. We ensure that treatment and support is provided to a person to meet their mental health needs while awaiting a mental health bed by working collaboratively with our acute hospital partners. In those circumstances, the person receives mental health care and treatment from the Psychiatric Liaison Services (“PLS”). These are multidisciplinary teams based in the acute hospital which include Registered Mental Health Nurses and Consultant Psychiatrists. The person’s ongoing psychiatric assessment and treatment is coordinated by PLS, through the use of a High Risk Care Plan. This includes where a person is awaiting onward transfer to a mental health bed, as was the case with Ms Petit. The High Risk Care Plan is a shared document that is placed in the medical notes and on the electronic record. It highlights the actual and potential risks, as well as plans to minimise the outlined risks. It is a live document and reviewed regularly. While at Royal Surrey County Hospital, Ms Petit was assessed by a Consultant Psychiatrist who carried out a review of her medication. She was provided with support from a Psychiatric Liaison Team and received 1:1 observation by a Registered Mental Health nurse. While optimisation of treatment in a mental health hospital would have been the preferred option, the unavailability of an inpatient mental health bed meant that this was not possible and, instead, Ms Petit was provided with treatment for her mental health needs at the acute hospital. The Mental Health Act can be used to authorise detention and provide mental health assessment and treatment to a person admitted to an acute hospital setting. It is currently only the Emergency Department where the Mental Health Act cannot be used. This is recognised as a gap in the legislation. Therefore, where a person is admitted to the acute hospital and does not consent to remain there on a voluntary basis, steps are taken to detain the person under the Mental Health Act to a bed at the acute hospital wherever possible. This action can only be taken with the agreement of the acute Trust. The section under the Mental Health Act is commenced at the acute hospital and transfer to an inpatient mental health setting will take place as soon as a bed is available. Anyone detained under the Mental Health Act in an acute hospital would have a Responsible Clinician, who is a Consultant Psychiatrist. This ensures that medication can be introduced, where appropriate, and their response to treatment monitored. They also continue to benefit from the multi-disciplinary assessment and treatment of the Psychiatric Liaison Services while an inpatient mental health bed is awaited. Since Charne’s sad death in May 2023, the Trust has embarked on collaborative improvement work with our acute care partners through the Mind and Body Transformation as part of the Trust Provider Collaborative (which consists of SaBP, Ashford and St Peter’s, Royal Surrey County Hospital and also includes East Surrey Hospital, Epsom General and Frimley Park Hospital). This work is in recognition of the challenges the system faces to support people safely whilst they may be awaiting a mental health bed or be in the acute hospital with both physical and mental health needs. The programme has been designed to better integrate physical and mental healthcare, and support for people attending acute hospitals with a combination of needs, by improving outcomes, flow and experience of those with mental health needs, their carers and families. Each Trust now has a mental health senior lead whose role is to oversee the appropriate care and support for a person with mental health needs in their acute Trust through the deployment of the Enhanced Care Framework working collaboratively with SaBP PLS. As one of the Trust’s partners within the Mind & Body Provider Collaborative, Royal Surrey County Page 2 of 3 Hospital now has a Head of Nursing for Mental Health providing senior oversight of the collaboration across mental health and physical healthcare. While working within a legal framework acknowledged by the Government to be in need of reform, we and our partners within the health and care system must also react to increasing numbers of people presenting in crisis. I remain committed to continually improving the way in which we provide mental health care to those served by the Trust despite the bed availability difficulties faced and would very much welcome the resolution of this issue at a national level. I note that the PFD report has also been sent to NHS England who are most appropriately placed to address this issue nationally. On behalf of the Trust, I would like to offer our sincere condolences to Ms Petit’s family for their loss. Yours sincerely, Chief Executive Page 3 of 3
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