Ceara Thacker

Coroner's concerns

AI summary

Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, the residential advisor lacked training on safe intervention for hangings.

View full coroner's concerns

1. Throughout Ceara’s Involvement with the medical professionals and therapists, whether by Mersey Care, Mental Health Advisory team at the University or the GPs there is no evidence of any discussion around involving Ceara’s family in drawing up a plan or consideration of requesting consent from Ceara to discuss her situation with parents/family. It is accepted that Ceara was an adult and had full capacity, however, Ceara was a young adult, first time away from home who had history of mental health issues. It would have been helpful to have had these discussions so that if Ceara wanted that additional support from her family this could have been facilitated. That said it is unclear as to whether Ceara would have agreed to her family being involved, however, this line of enquiry would have been helpful.

The general approach with young people appears to be to encourage them to discuss their issues with their parents/family rather than asking for consent for the professionals to discuss it with the parents/family.

2. Concern was raised that once Ceara was found hanging, no attempts were made to cut her down. The pathologist gave evidence to the effect it would be difficult to say how quick the death would have occurred, however, there was a very small window after the hanging where a person could survive, be it with brain damage. He stated it was rare that an individual was not cut down. The Residential Adviser who found Ceara had received first aid training but this did not include anything in relation to hangings.

Responses

1 respondent

NHS England NHS / Health Body

30 Sep 2019 PDF

Action Planned

NHS England will focus on ensuring consent is reliably and consistently considered for family involvement in mental health care, particularly regarding complex electronic patient record systems and differing patient needs. They are also working with Universities UK to develop information sharing guidance and a consensus statement on sharing information without breaching confidentiality. (AI summary)

View full response

Dear Ms Bhardwaj

Re: Regulations 28 Report to Prevent Future Deaths Ceara Marie Thacker

I write further to the Regulation 28 report dated 30 September 2019 and received 1 October 2019, following the inquest you conducted into Ceara’s death. Please note that whilst your Regulation 28 letter was addressed to the NHS Improvement Patient Safety Team, NHS England and NHS Improvement are operating as a single organisation, and in responding to your Regulation 28 letter I have drawn on the insight of clinical and policy members of our mental health team. It would be helpful to us if any future Regulation 28 letter related to action in NHS England and NHS Improvement’s sphere of responsibilities was directed to us jointly at the contact address and email above.

In your letter you asked us to consider action related to requesting consent from young people to involve parents/family in their mental health care plan. You recognised some young people may refuse to give this consent, but we agree this does not detract from the importance of consistently seeking it. Whilst your concern was particularly directed at young adults, we agree it is important for anyone accessing mental services.

There is clear existing guidance on the importance of seeking consent to involve family and friends.1 Because of this we will focus our action to prevent future deaths on steps that would help ensure it is more reliably and consistently considered. This is potentially a complex undertaking, given the range of electronic patient record systems used in mental health services, and differing patient groups with different needs that need to be reflected within formats used to record information across a range of mental health services, and the need to work within the relevant legal frameworks, including giving due regard to information governance law, the Mental Capacity Act and the Mental Health Act. The NHS England & NHS Improvement mental health programme team will work with our partners in

1 Some of the key sources include:
• Consensus statement on information sharing prevention:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/27 1792/Consensus_statement_on_information_sharing.pdf
• Confidentiality and Information Sharing: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better- mh-policy/college-reports/college-report-cr209.pdf?sfvrsn=23858153_2
• The Triangle of Care

and.pdf

Ms Anita Bhardwaj Area Coroner for Liverpool and Wirral Gerard Majella Court House Boundary Street Liverpool L5 2QD

National Medical Director Skipton House 80 London Road SE1 6LH

16 December 2019

NHS England and NHS Improvement NHSX and NHS Digital to bring together key stakeholders to scope whether it would be possible to routinely prompt seeking consent to involve families within electronic clinical record systems. We will also explore if the completion of those prompts can be directly linked to national datasets, as this would open the potential for measurement and for targeting improvement support where it is most needed.

We will also continue to link with Health Education England who deliver a range of workstreams focused on improving the skills of all staff working in mental health services,2 as these skills underpin sensitive and challenging discussions with service users and care plans that genuinely engage family support. Our Long Term Plan work to transform community mental health care, including for young adults, has a specific focus on improving co-produced personalised care and support planning, in which carer and family involvement is important.

Increasingly universities are routinely asking for consent to contact students’ parents if support is felt to be needed, through registration questions phrased to ensure students understand the need for this. We are currently working with Universities UK to develop information sharing guidance and a consensus statement on when information can be shared without breaching confidentiality, and expect Universities UK to open consultation on draft guidance in the near future.

One of the actions to prevent future deaths that you directed to NHS Improvement was related to the content of first aid courses for members of the public. The NHS does not determine the content of public first aid courses. We understand the appropriate body to consider action would be the British Red Cross who are a direct provider of first aid training and whose curriculum is the basis for most first training provided by a range of independent training organisations in workplaces, etc. They can be contacted at contactus@redcross.org.uk

I hope that the information I have provided regarding how NHS England and NHS Improvement have responded to the concerns you raise will be some small comfort to Ceara’s parents, family and friends in their terrible loss. If you share this letter with them, please also share my sincere condolences.

I am very grateful to you for bringing to my attention the circumstances surrounding Ceara’s death.

Report sections

Investigation and inquest

On 18th May 2019 I commenced an investigation into the death of Ceara Marie Thacker, aged 19 years. The investigation concluded at the end of the inquest on 20th September 2019. The conclusion of the inquest was as follows:

Ceara Marie Thacker died as a result of Suicide

Ceara Marie Thacker died from:

Ia Compression of the Neck (Due to) b Hanging Ceara Marie Thacker was a 19 year old young lady who moved from Bradford to Liverpool in September 2017 to attend the University of Liverpool. Up until the age of 16 Ceara had been under Child and Adolescent Mental Health Services (CAMHS) in Bradford. Throughout her teenage years Ceara self-harmed. On 11 May 2018 Ceara was found deceased hanging . The toxicological analysis revealed the presence of alcohol (175mg – blood). Ceara’s first contact with mental health services in Liverpool was with the Primary Care Service, Talk Liverpool, in September 2017. Ceara registered with a GP in Liverpool on 30 September 2017. On 3 October 2017 Ceara presented herself at the Accident and Emergency department of the Royal Liverpool University Hospital with suicidal ideation and was low in mood. During the assessment in the Royal Liverpool University Hospital (RLUH) a mental state examination was completed which concluded Ceara was low and anxious, however had no current plan or intent to end her life, citing her family and friends as protective factors. The plan developed was for Ceara to see her G.P. to review her treatment, she was provided information and was signposted to Young Persons Advisory Service (YPAS). On 23 October 2017 Ceara saw the GP and discussed her anxiety and depression, she was noted to be coping mostly well but stated she could sometimes get very low. On 21 February 2018, Ceara attended the Royal Hospital accident and emergency department having overdosed on paracetamol and ibuprofen and once medically fit she was assessed by the mental health practitioner. During the assessment Ceara stated she had been struggling and her level of self-harm had increased but was unable to identify a trigger. Ceara was given similar advice again to when she attended the Accident and Emergency Department in October 2017. Ceara stated she found it difficult to take the medication and that it was not effective and did not like the way it made her feel. She was advised to discuss this with her G.P. who could discuss alternatives. The assessment noted that Ceara’s self-harm had increased in frequency and concluded that she had taken an impulsive overdose and she regretted taking the overdose. Despite stating she had good friends the note of the assessment later stated that friends were unaware and that she didn't feel she knew them well enough to talk about her difficulties (the assessment was never sent to the GP but this was a separate issue explored at the Inquest). On 13 February 2018 Ceara completed and dated a self-referral form to the Mental Health Advisory team, a service based in the University of Liverpool and supplementary to the NHS mental health services, but only sent the form to them on 22 February 2018, the day after she had taken the overdose. This referral was triaged on 26 March 2018 and an appointment then offered for 24 April 2018 (the delay of the appointment was a separate issue explored at the inquest). In this meeting she mentioned similar things to those mentioned in previous meetings. Ceara was not deemed to be of immediate risk. On 24 March 2018 Ceara completed a second self-referral to Talk Liverpool and was offered a telephone assessment for 10 April 2018. This was carried out by a cognitive behavioral therapist. This assessment concluded that Ceara presented as quite vulnerable and impulsive and reached the conclusion that Ceara was not suitable for cognitive therapy behavior therapy and referred her to a secondary service, the Single Point Access (SPA) team for a full mental health assessment. The referral to SPA team was received on the same day and was triaged the next day on 12 April 2018. The assessment is based upon the information on the referral and at a multi-disciplinary team meeting it was deemed suitable for a routine appointment namely in 6 weeks and Ceara was sent an appointment for 18 May 2018. Ceara did not attend this appointment as she died on 11 May 2018.

A number of other issues gave rise to exploration during the inquest, however, these were not matters relevant to this report.

Action should be taken

1. Consideration be given to the merits of incorporating into training, guidance or publications for health professionals, the importance and benefits of requesting consent from young, vulnerable adults to involve their parents/family in their mental health care plan; whether this is by way of including a question in assessment toolkits to prompt this discussion with the young adult or other methods.

2. Consideration be given to including any appropriate training or information that can be incorporated into the national first aid training on what to do when someone is found hanging (it is accepted that individuals at the time may not be able to follow any guidance depending upon their reaction to the situation).

Copies sent to

Mersey Care NHS TrustBrownlow Hill Medical Group

Inquest conclusion

Ceara Marie Thacker died as a result of Suicide

Ceara Marie Thacker died from:

Ia Compression of the Neck (Due to) b Hanging Ceara Marie Thacker was a 19 year old young lady who moved from Bradford to Liverpool in September 2017 to attend the University of Liverpool. Up until the age of 16 Ceara had been under Child and Adolescent Mental Health Services (CAMHS) in Bradford. Throughout her teenage years Ceara self-harmed. On 11 May 2018 Ceara was found deceased hanging . The toxicological analysis revealed the presence of alcohol (175mg – blood). Ceara’s first contact with mental health services in Liverpool was with the Primary Care Service, Talk Liverpool, in September 2017. Ceara registered with a GP in Liverpool on 30 September 2017. On 3 October 2017 Ceara presented herself at the Accident and Emergency department of the Royal Liverpool University Hospital with suicidal ideation and was low in mood. During the assessment in the Royal Liverpool University Hospital (RLUH) a mental state examination was completed which concluded Ceara was low and anxious, however had no current plan or intent to end her life, citing her family and friends as protective factors. The plan developed was for Ceara to see her G.P. to review her treatment, she was provided information and was signposted to Young Persons Advisory Service (YPAS). On 23 October 2017 Ceara saw the GP and discussed her anxiety and depression, she was noted to be coping mostly well but stated she could sometimes get very low. On 21 February 2018, Ceara attended the Royal Hospital accident and emergency department having overdosed on paracetamol and ibuprofen and once medically fit she was assessed by the mental health practitioner. During the assessment Ceara stated she had been struggling and her level of self-harm had increased but was unable to identify a trigger. Ceara was given similar advice again to when she attended the Accident and Emergency Department in October 2017. Ceara stated she found it difficult to take the medication and that it was not effective and did not like the way it made her feel. She was advised to discuss this with her G.P. who could discuss alternatives. The assessment noted that Ceara’s self-harm had increased in frequency and concluded that she had taken an impulsive overdose and she regretted taking the overdose. Despite stating she had good friends the note of the assessment later stated that friends were unaware and that she didn't feel she knew them well enough to talk about her difficulties (the assessment was never sent to the GP but this was a separate issue explored at the Inquest). On 13 February 2018 Ceara completed and dated a self-referral form to the Mental Health Advisory team, a service based in the University of Liverpool and supplementary to the NHS mental health services, but only sent the form to them on 22 February 2018, the day after she had taken the overdose. This referral was triaged on 26 March 2018 and an appointment then offered for 24 April 2018 (the delay of the appointment was a separate issue explored at the inquest). In this meeting she mentioned similar things to those mentioned in previous meetings. Ceara was not deemed to be of immediate risk. On 24 March 2018 Ceara completed a second self-referral to Talk Liverpool and was offered a telephone assessment for 10 April 2018. This was carried out by a cognitive behavioral therapist. This assessment concluded that Ceara presented as quite vulnerable and impulsive and reached the conclusion that Ceara was not suitable for cognitive therapy behavior therapy and referred her to a secondary service, the Single Point Access (SPA) team for a full mental health assessment. The referral to SPA team was received on the same day and was triaged the next day on 12 April 2018. The assessment is based upon the information on the referral and at a multi-disciplinary team meeting it was deemed suitable for a routine appointment namely in 6 weeks and Ceara was sent an appointment for 18 May 2018. Ceara did not attend this appointment as she died on 11 May 2018.

A number of other issues gave rise to exploration during the inquest, however, these were not matters relevant to this report.

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