Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0161, written 24 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Mar 2025 |
|---|---|
| Reference | 2025-0161 |
| Deceased | Claire Driver |
| Coroner | Tanya Rawden |
| Coroner area | South Yorkshire (West) |
| Category | Mental Health related deaths · Community health care and emergency services related deaths |
| Organisation named | South West Yorkshire Partnership Teaching 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Yorkshire Partnership NHS Foundation Trust Lane South West Fieldhead Ouchthorpe Wakefield WF1 3SP CORONER I am Tanyka Rawden, Senior Coroner for the Coroner's area of South Yorkshire (West). 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 INVESTIGATION and INQUEST On 27 September 2024 I commenced an investigation into the death of Claire Louise DRIVER. The investigation concluded at the end of the inquest on 21 March 2025. The conclusion of the inquest was Open. CIRCUMSTANCES OF THE DEATH Claire Louise Driver had a past medical history of schizoaffective disorder and polysubstance misuse. She had been known to mental health services since 2011 and was first admitted to hospital in 2014. She had a lengthy hospital admission between 2018 and 2021 and on discharge was supported by a care co-ordinator from the enhanced community mental health team. By May 2023 she had started to disengage with that team. She was seen by her care co-ordinator on 28 November 2023 whilst in police custody and was not displaying any signs of psychosis. On 5 December 2023 the enhanced community mental health team were contacted by a PCSO reporting Claire was stealing from local shops. A home visit on 7 December 2023 from the enhanced community mental health team was unsuccessful. 1 2 3 4 On 8 December 2023 Claire’s former partner contacted the enhanced community mental health team reporting concerns for her welfare and that she was being sexually exploited. On 13 December 2023 a housing officer called the enhanced community mental health team to raise concerns about Claire. On 15 December 2023 a housing officer called the enhanced community mental health team to say Claire was intoxicated and there were concerns around substance and alcohol misuse. On 16 December 2023 Claire was arrested for indecent exposure. She was intoxicated. She was not seen by the enhanced community mental health team whilst in police custody. On 11 January 2024 the enhanced community mental health team and fire service visited Claire’s address and could not gain access. On 16 January 2024 Claire was arrested. She was assessed under the Mental Health Act and detained under s2, and later s3. During that admission her medication was optimised, she began to engage with treatment, and her symptoms began to improve along with her insight into her condition. She began to take leave in preparation for discharge. She was seen in the community by the enhanced community mental health team on 5 May 2024 and discharged from hospital on 7 May 2024. Post discharge she maintained the allocation of a care co-ordinator from the enhanced community mental health team. Following initial unsuccessful attempts at contact, Claire was seen on 13 May, 14 May and 21 May 2024. She was concerned about side effects from her medication and was reluctant to take it. She was also seen to be drinking beer. After several failed visits she was last seen on 1 June 2024 when no concerns were raised, albeit the enhanced community mental health team did not enter her flat or conduct a lengthy visit. On 13 June 2024 she was arrested and taken to Court where she was granted bail. Claire was reported missing to South Yorkshire Police on 24 June 2024 She was assessed as a medium risk and missing person enquiries began. The last sighting of her by a member of the public was on 24 June 2024. On 2 July 2024 she was reassessed as a high risk missing person due to the amount of time she had been without her medication and that others had been found to be accessing her bank account. A dedicated investigation team was formed and a twenty two day search commenced covering an area 7.8 square miles in and around Silkstone. On 29 July 2024 she was moved to the long-term missing portfolio and presumed to be deceased. On 14 September 2024 Claire was in a state of significant decomposition in a shallow stream in woodland off Kinemoor Lane, Silkstone in Barnsley. found She was identified by her fingerprints. The cause of death at post mortem examination was: 1a. Unascertained. 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) The inquest heard there were only two attempts to see Claire by the enhanced community mental health team between 28 November 2023, when she was seen in police custody, and 16 January 2024, when she was detained under the Mental Health Act, despite clear evidence her mental health was deteriorating. It was accepted in evidence a more assertive approach to attempt to engage Claire, and in complex cases generally, could have been used and there could have been better liaison between the police and the enhanced community mental health team when Claire was in custody. A more assertive approach and better liaison could have prevented Claire relapsing to such an extent she needed to be detained under the Mental Health Act. (2) The inquest heard that training on the effect of substance misuse on mental health conditions is not mandatory for all staff and would be of assistance when caring for patients such as Claire. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, South West Yorkshire Partnership NHS Foundation Trust, have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 May 2025. 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 I have sent a copy of my report to the Chief Coroner and to the family of Claire Louise Driver. 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 5 6 7 8 me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 24 March 2025 9 Signature Tanyka Rawden H.M Senior Coroner for
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.
16th May 2025 Tanyka Rawden HM Senior Coroner, South Yorkshire (West) Medico-Legal Centre Watery Street Sheffield S3 7ES Dear Ma’am, Regulation 28 Response – Claire Driver Chief Nurse / Director of Quality and Professions Trust Headquarters Fieldhead Hospital Ouchthorpe Lane Wakefield WF1 3SP Tel: 01924 316298 We write in response to the Regulation 28 report following the inquest touching the death of Ms Claire Driver. We would like to start this response by offering Ms Driver’s family our sincere condolences for their loss. We hope the information supplied in this response provides assurance that the Trust has carefully considered your concerns and has appropriate systems or processes in place in respect of the concerns. We will take each concern in turn below. 1. The inquest heard there were only two attempts to see Claire by the enhanced community mental health team between 28 November 2023, when she was seen in police custody, and 16 January 2024, when she was detained under the Mental Health Act, despite clear evidence her mental health was deteriorating. It was accepted in evidence a more assertive approach to attempt to engage Claire, and in complex cases generally, could have been used and there could have been better liaison between the police and the enhanced community mental health team when Claire was in custody. A more assertive approach and better liaison could have prevented Claire relapsing to such an extent she needed to be detained under the Mental Health Act. In July 2024 NHS England (NHSE) began a review of the intensive and assertive community support available for those with serious mental health disorders, with Integrated Care Boards across the country reviewing current staffing provisions and numbers of service users who would access such services. NHSE are leading integrated care boards (ICBs) and other organisations in reviewing service delivery for people who require intensive and assertive community support, and we anticipate the publication of service standards for us to implement later this summer. As part of this review process the Trust established a working group to work across the whole of the organisation. This review focused on provisions available to our Enhanced teams, who deliver care to those with the most complex needs in the community whose care can involve a variety of agencies. This work is on-going. Those requiring intensive and assertive support have been identified within our teams and we have ensured they have the correct level of care. The enhanced teams are now working to develop a greater understanding of those service users who require an intensive and assertive approach. This gives greater ability for teams and leaders to follow the care journey for these services users and add clinical scrutiny and assurance as part of discharge planning, to ensure safe oversight and discharge with up-to- date risk assessments and care plans. FACT (Flexible Assertive Community Treatment Model) was adopted by the Trust in 2016 following a restructuring of community mental health services. The outcome of this review was the establishment of Core teams and Enhanced teams, that people would be referred to dependant on their assessed level of complexity and needs. All the Trust’s Enhanced teams use FACT as a means of identifying those service users who need additional input for a period of time over and above that described in their care plan, for example because of an observed decline in their mental state. This would include those recently discharged from hospital, with relapsing mental health or other serious mental health related concerns. Service users are categorised using a risk informed traffic light grading (RAG rating) dependent upon presenting need, with those graded as in the red zone being discussed each morning by the full multi-disciplinary team (MDT). The MDT meeting can also be used to provide a forum for staff to discuss service users where there may be concerns about their presentation, but who may not meet the threshold to be red on the FACT list. The aim of providing such additional support is to minimise or avoid any further deterioration and promote a swift recovery from any symptoms of relapse. To support the consistent implementation of FACT and the intensive and assertive approach to care, a caseload management tool is currently being piloted that will provide assurances that all service users within the Enhanced Team are discussed with a relevant clinical lead/team manager. This will ensure that clinicians receive additional case management support and ensure that all contacts, attempted contacts, and meetings are recorded within the notes, and that those who meet the criteria for benefiting from a more assertive approach are consistently identified and supported. 2. The inquest heard that training on the effect of substance misuse on mental health conditions is not mandatory for all staff and would be of assistance when caring for patients such as Claire. A new initiative of Integrated Co-occurring Needs (ICoN) is being set up in Barnsley that will bring together co-located workers from substance misuse services, mental health services and social care services to work with people with co-existing mental health and substance misuse issues. The Trust are currently working with partners to provide mental health nurses into the initiative. The model is operational and is being reviewed by local commissioners. In addition, the Barnsley district has a service commissioned by Barnsley Metropolitan Borough Council called Waythrough (previously referred to as Recovery Steps) for people within its population who want to address their drug and alcohol issues. The service is accessed by self-referral. The Barnsley mental health services, inclusive of the Enhanced Community Mental Health Team, maintains professional links to support users of both services in a joined-up manner. All Barnsley mental health staff are aware of the referral process to Waythrough and will endeavour to assist someone who is motivated to make the move towards contacting drug and alcohol services. Working with people with co-existing mental health problems and substance misuse issues has been included as a priority area of the mental health care group’s Learning Needs Analysis, which forms the basis of the training programme for all staff. Public Health England have made available an eLearning course – Better Care for people with co-occurring mental health and alcohol/drug use conditions, which has been made available to Trust staff. This is an essential to job role course with staff in the relevant teams, which would include those working with people with complex needs and those in the enhanced pathway, being identified to complete the course through their supervision or annual appraisal. Completion of this course is then registered on the persons’ individual training record. In summary, approaching the training in this way in effect ensures that those clinical colleagues who require this training receive it. I do hope the above information is of assistance and answers the concerns raised within your Regulation 28 report following the sad death of Ms Claire Driver. Yours sincerely, Chief Nurse / Director of Quality and Professions South West Yorkshire Partnership NHS Foundation Trust
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