Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0610, written 29 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 | 29 Oct 2024 |
|---|---|
| Reference | 2024-0610 |
| Deceased | Jamie Harding |
| Coroner | Sean Horstead |
| Coroner area | Essex |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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: 1. CEO of Essex Partnership NHS Foundation Trust 1 CORONER I am Sean Horstead, HM Area Coroner, for the coroner area of Essex 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 20th June 2022 I commenced an investigation into the death of Jamie Harding, aged 31 years’. The investigation concluded at the end of a 5-day inquest on 12h April 2024. The medical cause of death was confirmed as: I (a) Multiple severe Injuries I (b) Fall from Height II Psychotic Disorder The Deceased had been under the care of the Essex Partnership NHS Foundation Trust (EPUT) Essex Support and Treatment for Early Psychosis (ESTEP) between 2017 and 2020 and he had been prescribed anti-psychotic medication and allocated a Care Coordinator. The inquest heard evidence that Jamie had engaged relatively well with his care plan and was reporting improvements in his symptoms. However, he began to disengage with services in 2019, which appears to have coincided with the replacement of his Care Coordinator. He was discharged from EPUT services in November 2020. Jamie’s GP continued to be prescribed anti-psychotic medication. Two separate and urgent GP referrals were made to EPUT in November 2021 requesting an urgent review of Jamie, as he was hearing voices, experiencing paranoia, and reporting that his medication was not working. His mother also contacted EPUT directly. On 18 January 2022, Jamie was assessed by EPUT’s First Response Team (FRT) via telephone. Jamie described his symptoms, reported that he was binge drinking, and requested different medication. A plan was put in please 1 for Jamie to self-refer to a drug an alcohol service, and for his case to be discussed in a Multi-Disciplinary Team meeting (‘MDT’). The evidence disclosed that in the six months that followed this assessment there were a series of significant and repeated failures on the part of EPUT employees, together with inadequacies in the systems of operation of EPUT’s First Response Team, in the care, management and treatment provided to Jamie. My Narrative Conclusion recorded that the Deceased took his own life whilst the balance of his mind was disturbed and, further, recorded that a number of significant and repeated failures contributed to the avoidable death. The cumulative effect of these failures amounted to a gross failure to provide Jamie with basic medical care at a time that his condition clearly required it and, in this respect, neglect directly contributed to Jamie’s death. 4 CIRCUMSTANCES OF THE DEATH On the 3rd of June 2022 Jamie, accompanied by his mother, presented at Basildon Hospital A&E Department in crisis and seeking help for his further deteriorating mental health on a background of some three days lack of sleep and ineffective anti-psychotic medication failing to ameliorate the on-going and extreme paranoia and psychotic symptoms he was experiencing. In the context of on-going suicidal ideation and a subjective mood score recorded as 0/10, he was appropriately referred to the Mental Health Liaison Team (MHLT) for assessment by the A&E doctor. The assessment subsequently undertaken by the MHLT practitioner was inadequate and failed to appropriately act upon relevant information available to him including (but not limited to) information provided by Jamie’s mother regarding her son’s on-going suicidal ideation and her (and Jamie’s) expressed request for him to be admitted to hospital as a voluntary in-patient as she, and Jamie, did not feel able to keep him safe. Although the MHLT clinician gave evidence that he had concluded that Jamie required and would benefit from a period of admission as an in-patient, no such admission was sought or planned. Instead, Jamie was discharged home with a plan for him to be seen the following day by the Home Treatment Team. He was provided with a (daily) tablet of Zopiclone for the next seven days. Within hours Jamie had taken his own life having fallen a significant height from a window at his home address. The failure by the MHLT practitioner to initiate the process for Jamie’s admission to an in-patient bed constituted a clear missed opportunity to ensure appropriate and likely effective steps were taken to mitigate his high risk of acting upon his clear suicidal ideation. 2 The cumulative effect of the series of serious failures in the six months preceding the events of the 3rd of June amounted to a gross failure to provide Jamie with basic medical care at a time that his condition clearly required it. In this respect, neglect directly and more than minimally contributed to Jamie’s death. The failures identified included: (a) a serious failure to adequately follow up a plan identified in an assessment undertaken on the 18th January 2022 by a First Response Team (FRT) Assessor and a Trainee Doctor. The lack of any adequate follow up led directly to a failure to conduct a full Multi- Disciplinary Team Meeting (MDT) in respect of Jamie’s complex, on- going presentation involving increasing paranoia and psychotic-like symptomology in conjunction with on-going alcohol misuse; (b) a failure to undertake an urgent medication review over the same six- month period despite repeated requests for the same from GPs, Jamie himself and his mother; (c) the failure to hold a full MDT was a significant missed opportunity to allocate a Care Coordinator to Jamie and a missed opportunity to involve the Dual Diagnosis Service in Jamie’s care; (d) absent a full MDT and the allocation of a Care Coordinator, there was a serious missed opportunity to develop an appropriate Care Plan for Jamie and undertake regular, up-dated risk assessments regarding self-harm and suicide; (e) On the 20th May an EPUT Consultant Psychiatrist declined to undertake a review of Jamie’s medication, or any further form of review as requested by Jamie’s GP: this too was a serious missed opportunity. 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. – (a) The accepted absence of effective formal, compulsory training for clinicians regarding the Dual Diagnosis (DD) pathway and what it does and does not provide, how to access it and the potential benefits of it. The evidence confirmed that practitioners outside of the DD 3 workers/pathway were unaware how they could contact them, including directly. (b) In addition to weak record keeping and poor communication with patients and their families, the evidence revealed the lack of a robust and reliable system to ensure that the FRT deals with its caseload efficiently and effectively and particularly how it flags and then follows up referrals to and queries from other services/clinicians contributing, in turn and on the facts of this case, to the significant failure to hold an MDT. The FRT did not follow up (as it was accepted it should have) the referral (via a self-referral) to Open Road or the referrals for a medication review. Had there been such follow up, EPUT evidence confirmed that there would likely have been a discussion of Jamie’s case at a full MDT with the likely allocation of a Care Coordinator, the likely involvement of the Dual Diagnosis pathway and the likely use of the RAG rating system to ensure on-going risk assessment. In my opinion these features give rise to a clear risk of future deaths and must be addressed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 Monday 23rd December 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 family of the deceased, via their instructed lawyers at Leigh Day Solicitors. I am also under a duty to send the Chief Coroner a copy of your response. 4 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. 9 29.10.2024 HM Area Coroner for Essex Sean Horstead 5
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.
19 December 2024 Private and Confidential Mr Sean Horstead Area Coroner for Essex Coroner’s Office Seax House Victoria Road South Chelmsford CM1 1QH Dear Sir, Mr Jamie Harding (RIP) Chief Executive Office The Lodge Lodge Approach Wickford Essex SS11 7XX Tel: 0300 123 0808 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 29th October 2024, received by the Trust on 7th November 2024 in respect of the above, which was issued following the inquest into the death of Mr Harding, whose Inquest concluded on 12th April 2024 I would like to begin by extending my deepest condolences to Mr Harding’s family. The Trust sympathises with their 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 Mr Harding’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised. It is noted that the Regulation 28 report includes concerns relating to the Dual Diagnosis support provided by the Trust. In order to provide clarity and by way of context, EPUT employs the definition of dual diagnosis to refer to people with a severe mental illness (including schizophrenia, schizotypal and delusional disorders, bipolar affective disorder, and severe depressive episodes with or without psychotic episodes and personality disorders) and those with active misuse of substances (the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage) as per the NICE CG180. EPUT acknowledges that for people with Mental Health and Substance Misuse issues as National Guidelines suggest, having dual diagnosis teams/ services does not work as this could lead to further marginalization and social isolation (NICE Guidelines Quality Statement QS188). Dual Diagnosis is too common to be only handled by specialist workers. EPUT’s provision is there are individual specialist workers working across west, north east, south and mid Essex. In mainstreaming care for this service user group, the aim is to assist with social inclusion, tackle stigmatisation and provide timely access into appropriate support. Both Mental Health and Substance Misuse workers are experts in their own fields any therefore effective joint working is key to successful recovery and in EPUT there are Dual Diagnosis clinicians who provide a wrap around, add on service to clinicians with those clients in active addiction with complexities that require extra support into treatment. The Dual Diagnosis workers are registered Social Workers employed at band 6 or 7 on the NHS pay scale. We have previously had nurses in this position but at present, all our Dual Diagnosis Workers are Social Workers. The Dual Diagnosis workers work with the mental health teams and drug and alcohol services part of the Essex Drug and Alcohol Partnership (EDAP). They work within drug and alcohol services office one day a week. The rest of the week they work out of the offices of the community mental health services. The Dual Diagnosis workers provide short term interventions for up to eight weeks to support engagement with services, joint working and working with clients around motivation to change. They use solution focused practice and motivational interviewing techniques to do this. The aim of these interventions is to improve access to treatment and support, enable effective joint working and communication and, to actively involve clients in their treatment journeys. The Dual Diagnosis Workers also provide advice, guidance and consultation where needed. Concern a) The accepted absence of effective formal, compulsory training for clinicians regarding the Dual Diagnosis (DD) pathway and what it does and does not provide, how to access it and the potential benefits of it. The evidence confirmed that practitioners outside of the DD workers/pathway were unaware how they could contact them, including directly. Response: In carrying out our review of this case, it has been noted that the First Response Team (FRT) are aware on the process for contacting / accessing Dual Diagnosis support. However in light of the findings in this case, the FRT / the wider Trust have been reminded via Trust wide communications of the available support streams which includes access to the Trust’s quick access intranet page for dual diagnosis which gives clear guidance for staff. Additionally, the Trust provides Dual Diagnosis training within EPUT which covers the referral process and how to access support for an adult who has alcohol/substance misuse issues. This currently does not fall within the core requirement of all EPUT staff and the Trust is looking to extend this to all registered clinical staff within EPUT. The current expectation is for training to be completed once and the Trust is exploring the benefit to changing the requirement to be undertaken every 3 years. As was highlighted through the evidence presented at this Inquest, a key area of dual diagnosis working is robust system partnerships. We currently host an Essex Wide Dual Diagnosis Working Group to ensure better working relations with system partners and develop/improve the services through any learning and concerns raised within this forum. There is also a Dual Diagnosis Learning from Deaths Group hosted within EPUT that discusses any recent learning points from Internal Reports with a view to identify, action and share learning and implementation accordingly. There has been a re-launch of Dual Diagnosis steering group in April 2024. This group includes EPUT, primacy care and 3rd sector coming together with an aim to foster partnership / collaborative working. The First Response Team (FRT) has a dual diagnosis worker attached to the team who provides specialist advice and guidance and links when referred. Whilst this member of the team does not hold their own case load, they are a source of advice and support generally across the Trust. Concern b) In addition to weak record keeping and poor communication with patients and their families, the evidence revealed the lack of a robust and reliable system to ensure that the FRT deals with its caseload efficiently and effectively and particularly how it flags and then follows up referrals to and queries from other services/clinicians contributing, in turn and on the facts of this case, to the significant failure to hold an MDT. The FRT did not follow up (as it was accepted it should have) the referral (via a self-referral) to Open Road or the referrals for a medication review. Had there been such follow up, EPUT evidence confirmed that there would likely have been a discussion of Jamie’s case at a full MDT with the likely allocation of a Care Coordinator, the likely involvement of the Dual Diagnosis pathway and the likely use of the RAG rating system to ensure on-going risk assessment. Response: The Trust has implemented the Management and Supervision Tool (MaST) caseload management tool, which is improving how our care coordinators (and their supervisors) electronically manage their caseloads. This is a nationally developed framework which links in with current electronic systems to provide algorithms and indicators for increasing risk as well as disengagement and other relevant factors that would be discussed within an MDT setting. In addition, the tool would automatically generate a RAG rating for a patient based on the inputted data; by way of further safety netting this this would support clinical decision making around which patients should be presented to the MDT meeting based on relevant / emerging risk factors. In addition, the Trust has established a Trust Safety Improvement Plan focusing on disengagement, with a clear objective of supporting patients who may require additional layers of overall support. The Trust is monitoring the use of this tool via regular audits. It is encouraging to note that national research evidence demonstrates that staff using this tool become more effective at recognising patients at risk, and has also improved clinical record keeping, which is a further area of priority focus for the Trust. Again, the use of this tool is being monitored. The Trust is working to ensure, as far as we can, we take a consistent approach to patient care, however as each case is different, there is a need to apply clear clinical judgement and safe practice to each patient interaction, whilst at the same time appreciating context, available clinical tools / policies and guidance as required. 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 know 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. No doubt a copy of this reply will be shared with the family of Mr Harding. Yours sincerely, Chief Executive
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