Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0537, written 9 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Oct 2024 |
|---|---|
| Reference | 2024-0537 |
| Deceased | Nigel Hammond |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State Department of Health and Social Care The Chief Executive Norfolk and Suffolk NHS Foundation Trust, Suffolk County Council, Head of Social Work Mental Health Services 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 18th March 2024 I commenced an investigation into the death of Nigel Hutton HAMMOND The investigation concluded at the end of the inquest on 8th October 2024. The conclusion of the inquest was that the death was the result of: - Suicide, whilst the balance of his mind was disturbed. The medical cause of death was confirmed as: 1a Left Middle Cerebral Artery infarction, Traumatic Brain Injury 2 Depression, Lymphoma 4 CIRCUMSTANCES OF THE DEATH Nigel Hammond’s death was verified at 10:20 on 14th March 2024, at the Addenbrooke’s Hospital, Cambridge. On the 11th March 2024 Nigel fell from address. at his home An ambulance was called, and Nigel was initially taken to the Ipswich Hospital but was transferred to the trauma centre at Addenbrooke’s hospital due to the extent of his injuries. Nigel succumbed to the injuries received in the fall, three days later. Nigel had suffered with his mental health for a protracted period, and it is more likely than not that his fall from the window was a deliberate attempt to end his life. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given 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 as follows. – 1. In late 2018 Nigel became seriously mentally unwell and was admitted to a Mental Health Unit, under the Mental Health Act provisions, for a period of 3 months. Whilst admitted, Nigel was diagnosed with advanced lymphoma (a lymphatic cancer) and upon discharge from the Mental Health Unit spent a further 3 months in hospital being treated for this. 2. Nigel found his Mental Health Unit admission very traumatic and was described as ‘terrified’ of the thought of ever being admitted again. 3. Upon his release, his family, carers, Mental Health Home Treatment team, worked together to provide exemplary care for Nigel, whose health stabilised and in 2020 his care was transferred back to his own General Practitioner. 4. Nigel remained well until Friday 8th March 2024, when due to his decline in mental health he was taken to see his GP, and on the 9th March 2024 Nigel was prevented by family intervention from ending his life by . 5. This incident led to Nigel’s family speaking to the on duty Authorised Mental Health Professional (AMHP) from the Suffolk Emergency Duty Service Team, on the evening of 9th March 2024. An AMHP is a mental health professional approved by a local social services authority to coordinate the mental health assessment and admission to hospital, of individuals requiring admission under the Mental Health Act provisions 6. In evidence, the court heard that the AMHP, in line with Nigel’s family and his own wishes, agreed that an admission to hospital would not be in Nigel’s best interest. The AMHP identified that the successful home treatment regime previously in place would be the ideal care package for Nigel. This arrangement would also be consistent with the ‘least restrictive principle’ which surrounds the application of Mental Health legislation. 7. That said, although Nigel did not meet the criteria for immediate admission, the AMHP believed Nigel was mentally very unwell, and in need of immediate support. The court heard that such support would be available within a 4-hour target time, from the emergency Crisis Resolution and Home Treatment Team. 8. However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team. 9. The court heard that the normal route for such referrals was via the GP Surgery, or primary care Mental Health Nurse, neither of whom in Nigel’s case would have been available before 08:00 on Monday 11th March 2024. Nigel’s fall which led to his death, occurred at 06:25 that morning. 10. I am concerned, as had the AHMP in Nigel’s case been able to directly refer him to the Crisis Resolution and Home Treatment Team on the 9th March 2024, mental health professionals would have attended, and been able to provide additional support, advice and potentially additional treatment for Nigel, in all likelihood preventing his death. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 4th December 2024 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. 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;- 1. Nigel’s next of kin. 2. Nigel’s GP I am 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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 9th October 2024 Nigel Parsley
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.
Parliamentary Under-Secretary of State for
Patient Safety, Women’s Health and Mental Health
39 Victoria Street
London SW1H 0EU
23 December 2024
Our ref:
HM Senior Coroner Nigel Parsley
The Coroners Court and Office
Beacon House
Whitehouse Road
Ipswich
IP1 5PB
By email:
Dear Mr Parsley,
Thank you for the Regulation 28 report of 9 October 2024 sent to the Department of Health
and Social Care about the death of Nigel Hutton Hammond. I am replying as the Minister
with responsibility for patient safety and mental health.
Firstly, I would like to say how saddened I was to read of the circumstances of Nigel’s death
and I offer my sincere condolences to his family and loved ones. The circumstances your
report describes are very concerning and I am grateful to you for bringing these matters to
my attention. Thank you for the additional time provided to the Department to respond to the
concerns raised in your report.
In preparing this response, my officials have made enquiries with NHS England and Norfolk
and Suffolk NHS Foundation Trust to ensure we adequately address your concerns.
The report raised concerns about Approved Mental Health Professionals (AMHPs) not being
permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment
Team provided by the Trust. You were concerned that had the AHMP been able to directly
refer Mr Hammond to the Crisis Resolution and Home Treatment Team, they could have
supported him and possibly prevented his tragic death. I have been informed that Norfolk
and Suffolk NHS Trust has worked jointly with Suffolk County Council to confirm a guidance
protocol. This will foster better communications and understanding between the AMHP staff
and crisis team, emphasising the need for discussion and communication prior to Mental
Health Act assessments. This allows them to consider the least restrictive care pathways.
The protocol will mean that through speaking to each other before the assessment or
decision to stand down an assessment AMHP staff mitigate any need to go through the GP.
Additionally, Norfolk and Suffolk NHS Trust is clarifying the need for this communication
where there is a determination to stand down a Mental Health Act assessment, in order to
make the best person-centred mental health plan for an individual.
I understand that the Trust will be providing further information on these points in its response
to your report.
I have been assured by NHS England that crisis services, including Crisis Resolution Home
Treatment Teams, are available at short notice to help individuals resolve a mental health
crisis or to support them while it is happening. Additionally, from this year, all mental health
providers in England offer access to 24/7 age-appropriate crisis support through NHS 111
via the ‘select mental health option’ – making it easier than ever to seek help.
NHS England’s ambition is not just to improve the access points to specialist mental health
services, but to bring significant improvements and expansion in the services that ‘sit behind’
these access points so that people can be facilitated to access support that meets their
needs and preferences in a more timely way. To this effect, NHS England is beginning to
measure response times to those presenting to urgent and emergency mental health
services, either in community and/or emergency departments, within the appropriate
timescales.
Furthermore, I’d like to reassure you that over the past few years, the NHS has been
developing a new community mental health framework to improve community support for
people with severe mental illness.
As part of our mission to build an NHS fit for the future, NHS England is working to make
sure more mental health care is delivered in the community, closer to people’s homes,
through new models of care and support, so that fewer people need to go into hospital and
that beds are available for when people need higher levels of support.
In addition, in September 2023 the multi-sector and cross-government suicide prevention
strategy for England was published. The five-year strategy set out actions aimed at reducing
the rates of suicide in England and work continues to implement these actions.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Yours sincerely,
PARLIAMENTARY UNDER-SECRETARY OF STATE FOR
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH
Senior Coroner, Nigel Parsley
Suffolk Coroner’s Court
Beacon House
Whitehouse Road
Ipswich
IP1 5PB
Email:
By email only
Dear Senior Coroner Parsley
NSFT Trust Management
Norfolk & Suffolk NHS Foundation Trust
Floor 7
County Hall
Martineau Lane
Norwich
NR1 2DH
Tel: 01603 421421
4 December 2024
Regulations 28 and 29 (coroners investigations regulations 2013) notification made in response to the
death of Nigel Hammond
I write in response to the Regulation 28 report made on 9th October 2024 in respect of concerns raised at the
inquest touching on the sad death of Nigel Hammond which concluded on 8th October 2024.
I have reviewed the report in its entirety and note that Mr Hammond had previously received successful home
treatment in 2020. The concern raised at inquest related to:
8.
9.
10.
…..the court was told that an Approved Mental Health Professional (AMHP), despite their role in the
coordination of the mental health assessment and admission to hospital of a patient, were not
permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.
The court heard that the normal route for such referrals was via the GP Surgery, or primary care
Mental Health Nurse, neither of whom in Nigel’s case would have been available before 08:00 on
Monday 11th March 2024. Nigel’s fall which led to his death, occurred at 06:25 that morning.
I am concerned, as had the AMHP in Nigel’s case been able to directly refer him to the Crisis
Resolution and Home Treatment Team on the 9th March 2024, mental health professionals would
have attended, and been able to provide additional support, advice and potentially additional
treatment for Nigel, in all likelihood preventing his death.
We have liaised and worked jointly with our colleagues at Suffolk County Council and produced a guidance
document (Attachment A) to foster better communications between the teams emphasising the need for
discussion and communication between crisis team staff and AMHP staff prior to Mental Health Act
Assessments and where the AMHP staff are deciding to stand down an assessment but are aware an
individual will require follow up support. This will support making the best person-centred plan for an individual.
The local CRHT managers will monitor application of this guidance and will discuss its benefits or any required
adjustments in our partnership meetings going forward. Performance in this area will be tracked by operational
teams and reported to NSFT’s Clinical Governance Group. These actions will also be monitored and assured
by the NSFT Patient Safety Group, both groups chaired by the Executive Chief Nurse.
I hope this provides assurance that we continue to strive to provide the best possible service to all those
requiring our services in collaboration with our system partners.
Yours sincerely,
, Chief Executive Officer
Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH
Tel: 01603 421421 Web: www.nsft.nhs.uk
One Page information guide for AMHP’s re referrals to NSFT CRHTT (Suffolk Wide)
NSFT REFERRAL CRITERIA FOR CRISIS RESOLUTION AND HOME
TREATMENT TEAM (CRHTT)
The CRHHT is a 24-hour 7 day service. It is all-age inclusive and is a responsive
service for when someone is acutely mentally ill, or in severe mental health crisis,
and without intense CRHTT input, a hospital admission would be necessary.
There is also a Dementia Intensive Support Team (DIST) that works with people who
have a cognitive impairment but do not have a formal diagnosis. This service is
currently only operational during normal business hours and works to the same
principle of avoiding hospital admission.
GATEKEEPING/ MENTAL HEALTH ACT ASSESSMENTS (MHAA)
AMHPs are expected to contact the CRHTT, who act as gatekeepers, prior to
arranging a community MHAA. The purpose of this is to discuss possible
alternatives to MHAA/admission and consideration of the least restrictive alternative
to hospital admission.
This discussion is necessary even if the initial MHAA opinion appears to indicate
detention under the Act. This is considered best practice for collaboratively
formulating the best clinical outcome for the person and may lead to either home
treatment, signposting or access to other alternatives to hospital, for example the
use of a crisis bed.
The MHAA team should also check the if the person has a crisis contingency plan as
this may guide their decision making.
REFERRAL TO CRHTT post MHAA
Post assessment an AMHP can formally refer to the CRHTT. Generally, the patient
must be aware of and consent to the referral. Exceptions to this include where a
person may lack capacity to consent and if clinically appropriate a referral can be
made. Other factors that may support a home treatment referral include, a
supportive family who can be with the patient and assist with medication etc.
PROCESS
In making a referral, the AMHP must provide a social circumstances report (SCR),
and the Section 12 assessing doctor must make a medical entry on Lorenzo
(electronic patient healthcare record). If the AMHP does not have access to Lorenzo,
then the SCR can be emailed to the relevant CRHTT.
The MHAA team should formulate an initial safety plan with the patient (and their
family/carer where indicated)
.
If accepted for CRHTT the AMHP should convey the outcome to patient, including
when to expect the first contact with CRHTT, e.g. ‘CRHTT will contact you tonight to
arrange first visit’, and give the CRHTT 24-hour number to the patient and also
family/care giver if appropriate.
In circumstances where the CRHTT does not accept the referral, they should explain
the reasons and assist with any discussions of available alternatives.
Any onward referrals to other teams or services is the responsibility of the AMHP,
however the CRHTT will support the AMHP with this where necessary. .
West Suffolk CRHTT: crhttwestsuffolk@nsft.nhs.uk 01284 719724
East Suffolk CRHTT: crandhtte_east_suffolk@nsft.nhs.uk 01473 891810
Gt Yarmouth and Waveney: CRHT.GYW@nsft.nhs.uk 01493 337860
West Suffolk Community Teams: Bury North IDT:01638 558650
Bury South IDT: 01284 733188
East Suffolk Community Teams:
Central Adult Community Team: 01449 745200
Ipswich Adult Community Team: 01473 341100
Coastal Adult Community Team: 01473 279200
Version 1
Agreed: 3 December 2024
Review: December 2025
Nic Roper
Adult and Community Services
Endeavour House
8 Russell Road
Ipswich
IP1 2BX
3rd December 2024
Dear Senior Coroner Parsley,
Regulation 28 response of Suffolk County Council in respect of Nigel Hammond
We write in response to the Regulation 28 report dated 9th October 2024 concerning the
death of Mr Nigel Hammond on 14th March 2024.
Firstly, Suffolk County Council (SCC) would like to express our sincere condolences to
Nigel’s family. SCC are keen to ensure that the family and the Coroner’s concerns are
listened to and reflected upon.
Having reviewed the Regulation 28 report, points 8-10 relate to concerns raised that the
Approved Mental Health Practitioner (AMHP) on duty was unable to make a direct referral
to the Crisis Resolution and Home Treatment Team within NSFT (CRHTT) and that if they
could have done, mental health professionals would have attended and been able to
provide additional support, advice and potentially additional treatment for Nigel, in all
likelihood preventing his death.
Since the inquest into Nigel’s death, it has been established through joint meetings
between senior managers from both NSFT and SCC that AMHPs are able to refer to the
CRHTT but that not all AMHPs were aware of this and that the process for referral was not
clear across the AMHP service. The NSFT policy/ pathway information had not been
shared with SCC and the AMHP service- hence resulting in confusion and lack of clarity.
It is important to note that the family did speak to the NSFT 111 Service prior to their
discussion with the AMHP who was on duty, and this service was also able to directly refer
to the CRHHT as well (both services being provided by NSFT).
Following receipt of the Regulation 28, NSFT and SCC have worked jointly together to
develop a short and concise information guide for AMHPs on the referral criteria and
process in respect of all CRHHTs in Suffolk. This guidance has been shared with all
AMHPs across Suffolk and will be followed up for robust discussion via SCC’s AMHP
Service Forum and with all CRHTTs within NSFT.
Endeavour House, 8 Russell Road, Ipswich, Suffolk, IP1 2BX
www.suffolk.gov.uk
As a system we have agreed to work collaboratively together to review and monitor the
application of this guidance through already established joint partnership meetings. We
hope that this provides assurance that SCC and NSFT are working together as system to
improve the outcomes for people who require support from our services.
Assistant Director- Learning Disabilities, Autism and Mental Health
Adult and Community Services
Suffolk County Council
Endeavour House, 8 Russell Road, Ipswich, Suffolk, IP1 2BX
www.suffolk.gov.uk
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