Source · Prevention of Future Deaths

Sally Poynton

Ref: 2024-0267 Date: 14 May 2024 Coroner: Andrew Cox Area: Cornwall and the Isles of Scilly Responses identified: 2 / 4 View PDF

An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan for a patient with emerging mental illness who declined treatment, created significant care gaps.

Date 14 May 2024

56-day deadline 9 Jul 2024 est.

Responses identified 2 of 4

Other related deaths

Coroner's concerns

AI summary

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1) Mental Health a) In-patient care at Longreach Hospital

Approximately one year before Sally’s homicide, had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited Information Classification: CONTROLLED behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. was electively mute, fasting and drinking only distilled water. He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care. At inquest, accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, , referred to a ‘quandary’ in identifying how much of presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described as a ‘model patient.’ One of the most striking features of the evidence was the difficulty Sally then encountered in having re-assessed. Indeed, in the year that followed, despite multiple attempts, was not seen again by a doctor from the mental health team. It is noteworthy that did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care. I felt there were a number of points of learning: i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest; ii) A failure to discuss with Sally or the maternal side of family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult. It may be of note that there was a difficult family dynamic with an acrimonious separation of parents. father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s. iii) The absence of a plan detailing the route back for to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices; iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard. Information Classification: CONTROLLED v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while was an in-patient.

accepted that had he seen it at the time, he would have had further questions for Jacob. vi) A lack of understanding or professional curiosity about drug-taking and the extent to which, if at all, this contributed to presentation. It was accepted by that he had been misled by who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.

2) Community Mental Health Team i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain. I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly. ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice. iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was electively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances. iv) Discharging a patient’s referral without any clinical judgment. referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge. I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHAA, will result in additional burdens for what is an already over-stretched Information Classification: CONTROLLED workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.

Primary Care

There was an accepted lack in continuity in primary care after he moved from Sally’s address (and a GP in Marazion) to his father’s house in Ponsanooth (and a GP in Penryn.)

The inquest was told that there are now regular Multi Agency Safeguarding Hubs (MASH) where patients who may be known to both the mental health service and adult safeguarding are discussed.

It struck me that there may be value in someone from the ICB attending MASH meetings on behalf of GPs in Cornwall. That individual could then feed back information to the surgery where a patient was registered. In this instance, that would have provided with the ‘backstory’ she did not have, not being in receipt of records or the discharge summary from Longreach when she saw him and given the difficulties associated with taking a history from Jacob when he was mute.

I wonder if you feel an initiative in this regard would be sensible?

Responses

2 respondents

Department of Health Social Care Central Government

21 Jun 2024 PDF

Noted

The DHSC refers concerns to the Cornwall and Isles of Scilly Integrated Care Board, notes new guidance for discharge from mental health settings, and explains why they do not believe ICB representatives attending MASH meetings would reduce risk but describes no specific action. (AI summary)

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Dear Andrew,

Thank you for your Regulation 28 report to prevent future deaths dated 14 May 2024 about the death of Sally Poynton. I am replying as the Minister with responsibility for mental health and patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Sally’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

Your report raises concerns over inadequate action taken with regard to her son

on his discharge from hospital, lack of engagement with patients’ family members, the impact of staffing shortages on community mental health teams and a lack of continuity of care and communication between different primary care agencies.

I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.

From a national perspective, we recognise how vital it is that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital, and that people and their chosen carers are fully involved in the process. On 26 January 2024, new statutory guidance for discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults was published. The guidance provides clarity in relation to how health and care systems can work together to support discharge from all mental health inpatient settings and ensure the right support is in place in the community. The guidance also includes best practice on how patients, carers and family members should be involved in discharge planning.

We recognise that there are particular challenges around referrals and discharge where patients do not engage. In the 2024/25 priorities and operational planning guidance, NHS England has asked local health systems to review their community services by September 2024/25 to ensure that they have clear policies and practice in place for patients with serious mental illness, who require intensive community treatment and follow-up but where engagement is a challenge.

Turning to your concerns around the impact of staffing shortages on service delivery, the Government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we recognise the need to increase workforce capacity in NHS mental health services overall. Nationally, positive progress has been made on growing the mental health workforce which, as at December 2023, had increased by around 20,800 compared to 2019/20. In addition, the NHS Long Term Workforce Plan sets out an ambition to grow the mental health, primary and community care workforce by 73% by 2036-37.

With regard to your suggestion that representatives from integrated care boards (ICB) might attend multi agency safeguarding hubs (MASH) meetings on behalf of GPs, the Department does not believe this alone would reduce the risk of lack of timely information sharing as you envisage. This is because the average population covered by an ICB is 1.5 million people, with some considerably larger. It is unlikely therefore that one ICB representative could be responsible for knowing the circumstances of the individual primary care patients within their ICB’s footprints or that this would be a reliable mechanism for facilitating information sharing.

However, ICBs across England should ensure they have in place robust information sharing processes that connect information presented at MASH and other safeguarding meetings with the network of primary care providers. ICBs have dedicated safeguarding and mental health leads who are best placed to set up these processes within their local setting. Primary care professionals themselves remain best placed to attend relevant safeguarding meetings regarding individual cases. Primary care professionals should also work to transfer patient records from one practice to another in a timely way, when a patient registers with a new practice.

I should also add that information on the role and rights of a person’s Nearest Relative forms part of a series of factsheets on the Mental Health Act made available through the NHS website at: MH-CoP-Nearest-relative.pdf (assets.nhs.uk)

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Response Integrated Care Board Office of the Clinical Executive

10 Jul 2024 PDF

Action Planned

The ICB will work with place-based directors to develop options for addressing the GP gap in safeguarding processes, including the adult MASH, consulting with stakeholders, presenting options to the executive group, and preparing a business case for funding if required. (AI summary)

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Dear Mr Cox,

Sally Poynton regulation 28 report

I am writing in response to the regulation 28 report to prevent future deaths following the inquest into the tragic death of Sally Poynton.

The ICB have actively participated in the domestic homicide review in relation to Sally’s death. Two of our staff members have met Sallys family during DHR panel meetings, where we expressed our sincere condolences for their loss and for what happened to her family and partner. We acknowledge that Sally’s death may have been prevented if several things had been done differently. This includes participation by general practice in the adult multi agency safeguarding hub (MASH) in Cornwall; as identified in your regulation 28 report.

The ICB have considered the findings in your report;

‘The inquest was told that there are now regular Multi Agency Safeguarding Hubs (MASH) where patients who may be known to both the mental health service and adult safeguarding are discussed. It struck me that there may be value in someone from the ICB attending MASH meetings on behalf of GPs in Cornwall. That individual could then feed back information to the surgery where a patient was registered.’

The ICB has taken this matter seriously and the executive leadership of the ICB were presented with a paper in a formal executive group meeting. The paper provided an analysis of this issue and a proposal for how it should be addressed. The meeting took place on the 8 July 2024 and supported the proposal; which is described in this letter.

On behalf of the organisation, I provide below a reply to the specific request in your report; whether the ICB believes that such an initiative would be helpful. This includes a description of the current barriers to general practice attending the MASH.

Page 2 The ICB already recognised the need to address this issue. It is included in safeguarding team’s work plan. Enabling people to receive appropriate safeguarding support delivered by teams working together is a priority in our joint forward plan.

Prior to confirming our plan to address this issue, I have provided some background information, which we hope will be helpful in setting out the reasons behind our response.

The adult MASH in Cornwall takes place shortly after an adult safeguarding referral is received by the adult social care safeguarding service in Cornwall Council. The MASH meeting brings together key agencies to share information, assess the initial risk, plan the next steps and decide what actions that are required. The MASH is led by Cornwall Council adult safeguarding service.

The adult MASH is currently operating as follows. There is a MASH meeting daily. The MASH reviews some referrals that been received by adult social care in the last one or two working days. The MASH does not review all referrals but reviews those of high risk or high concern. It also reviews some cases which are identified as progressing to a Section 42 enquiry.

A s42 enquiry is the statutory process that the local authority must follow when there is reasonable cause for concern that an adult with care needs is experiencing abuse. The local authority may undertake s42 enquirers themselves or they can cause other agencies to do so. Many s42 enquiries require input from multiple agencies. Therefore, one of the purposes of the MASH is to decide if a s42 enquiry is needed and plan how agencies will work together to deliver this.

At present general practice is not represented in these MASH discussions. However, if the referral proceeds to a s42 enquiry, the GP practice will be included, where appropriate, as part of that plan including being invited to any meetings. This goes some way towards mitigation of the gap in the MASH in that when a safeguarding need is confirmed via the MASH, the GP practice is then included in the delivery of the safeguarding plan.

Therefore, there is GP practice involvement in adult safeguarding enquiries. However, as identified in the regulation 28 report, there is a gap in GP practice input in the early discussions that take place during the adult MASH.

The reason that general practice is not currently represented in the MASH is because of the way the MASH is conducted. A MASH is held as a series of conversations about a series of people. These people may be receiving services from one or more organisations across Cornwall. It would not be practical for to ask individual workers from all the organisations to attend for the one or two people they are supporting in the few hours after a referral was received. Therefore, it is common and accepted practice in any MASH that each agency sends one representative who will share information on behalf of the agency. They will also feedback to individual workers and update record systems.

Such arrangements work well for large organisations that provide services for one sector, such as hospital trust or the police.

It is not so straightforward for GP practices, for the reasons described above. It could not be practically arranged for each practice to join at a point when the conversation moves to the person registered at their practice.

Page 3 Another reason that general practice is not represented at the MASH is that for some people, adult social care can not immediately identify the GP practice that a person is registered with. There is a way that this can be done, using SMART card access to the NHS spine. Adult Social Care do not have access to a SMART card. They are able to establish the identity of practice by sending an e-mail to Primary Care Support England (PCSE). However, it may take a few days to receive a reply.

The adult MASH gap is already known to the ICB and we are aware that this gap affects five other safeguarding processes in Cornwall. These are;
• children’s multi agency referral unit,
• prevent and channel panel
• multi agency risk assessment conferences (for domestic abuse)
• Missing and childhood exploitation panels
• Multi agency public protection arrangements

To summarise the issues
1. There is no person identified that is able to represent general practice at the adult MASH. It is not practical for each general practice to be represented for each individual. This affects other processes

2. There is no person identified that is able to directly access GP records to provide information to inform the adult MASH.

3. Adult social care cannot consistently and quickly identify the identity of the GP practice to advise the GP practise that the MASH is taking place.

The ICB executive group reviewed this information and considered if the ICB could attend the MASH on behalf of general practice.

We agree that it is likely that the existence of such a role could help with information sharing and a provide a more effective assessment of risk. In order to fulfil this role safely, and GP MASH representative would need to have access to the GP records along with appropriate clinical supervision and support.

The provision of such a role would be outside of the legislative functions of ICBs as set out in the Health and Care Act 2022. The Act establishes ICBs as NHS organisations responsible for planning health services for their local population. ICBs manage the NHS budget for their local area and work with local providers of NHS services, such as hospitals and GP practices, to agree a joint five-year plan which says how the NHS will contribute to a wider integrated care strategy. ICBs are strategic rather than patient facing organisations.

National guidance encourages ICBs to delegate some of their resources and responsibilities to place-based partnerships; recognising the fact that much of the work needed to integrate services, improve population health and tackle inequalities needs to happen at a more local scale. The provision of person to liaise between general practice and the MASH comes under this remit of a placed based provision. It is better for the person if the operational delivery of safeguarding responses take place at a local level as part of a wider multi disciplinary team that can work together to support the individual.

In Cornwall and the Isles of Scilly, there are three place-based partnerships, known as integrated care areas; which are central, north and east. Each area is made of up primary care

Page 4 networks (PCNs) . PCNs are general practices working together in their areas in groups of practices with health, community, mental health, social care, and voluntary services.

Each of the PCNs across Cornwall and the Isles of Scilly are based on GP registered patient lists. They serve communities of 30,000 to 50,000 people. PCNs are small enough to provide the personal care valued by both people and GPs. They are also large enough to have impact and economies of scale through better collaboration between GP practices and others in the local health and social care system areas.

Our ICAs are connected to our ICB through placed based directors who are responsible for improving services in the local ICA. Their role is to lead the collaboration to achieve effective patient responses at scale, where appropriate. They also bring together the wider multi disciplinary teams. These multi disciplinary teams are best placed to provide a safeguarding response to people affected by abuse. It is therefore sensible that any function that provides the link with the MASH and general practice should be closely connected to these multi disciplinary teams.

We therefore believe that the development of a solution to this problem would be most effectively progressed in our place-based partnerships, rather than being hosted in the ICB which is more distant from those multi disciplinary teams. It is also our view that the matter of adult MASH should not be addressed in isolation and should include the other safeguarding processes affected. To address these as a whole will involve consultation with the ICAs, PCNs, adult social care, children’s social and other stakeholders to make sure we reach an appropriate solution.

We recognise our strategic responsibility to convene partners to tackle this issue and to provide safeguarding expertise and support to our place-based partnerships. It is our responsibility to work with our place-based partnerships and other stakeholder to develop a solution that meets the needs of people experiencing abuse. Should the solution identify that any new posts are required, then these would need to be funded. NHS England has set their expectations for ICBs not to spend over and above their allocated funding for the area. This expectation means we need to progress and funding requests though a system process. Decisions are made in partnership with key stakeholders and are therefore not solely within the control of the ICB. We do take this matter extremely seriously and therefore would support any business case for a solution to be considered as part of our system decision making process.

As I explained earlier in the letter, these actions had already been included in our future plans. Progress has been affected by our ICB redesign. NHS England required all ICBs to make a 30% reduction to running costs by 2025/6 with 20% to be delivered by 2024/2025. Cornwall and Isles of Scilly ICB took this opportunity to redesign our functions, including how we work with our place-based partnerships. This was so that are fit for the future and able to meet the requirements of the Health and Care Act 2022. The redesign resulted in the development of a new structure with new posts of place directors. The place directors are the connection between the ICB, ICAs and PCNs. These posts are critical to the effective progression of this issue and needed to be recruited to prior to commencing this work. All these posts have been recently filled and we are now in a position to take this forward

Page 5

In summary our ICB actions are;

Our chief nursing officer and head of nursing will work with the place-based directors to implement develop one or more options of how to address the GP gap in the six safeguarding processes, including the adult MASH.

1. The ICB will lead and support a consultation with general practice and other stakeholders on the options.

2. The options will be presented to our ICB executive group.

3. If any funding is required to implement the options, then a business case will be prepared and presented along with other business cases for our system during the annual commissioning planning rounds, at the end of 2024.

4. We appreciate that this does not provide an immediate solution but believe that the wider consultation is necessary to develop options that will work in practice. It will also give us the option to explore any digital solutions. There is some mitigation in that general practice are included in any section 42 enquiries, after the MASH.

I hope this provides the information you need as a response to the regulation 28 report, and please do not hesitate to contact me if you need any more information.

Report sections

Investigation and inquest

On 8 May, I concluded the inquest into the death of Sally Poynton who was stabbed to death by her son on 22 June 2021.

I recorded the cause of death as 1a) Knife wounds to neck and abdomen

I returned the following narrative conclusion. Sally Poynton was unlawfully killed. Had referrals for medical re-assessment of her assailant been accepted or a needs assessment conducted, on the evidence, it is more likely than not that the assailant’s deteriorating mental health would have been identified, a treatment plan instituted, and Sally would not have died when she did.

Circumstances of the death

This was a long and complex inquest involving multiple State agencies. I enclose a copy of my written judgment. In summary, my overview of the background to the case was as follows:

1) Sally was just 44 years of age when she was fatally stabbed on 22 June 2021. What compounds this tragedy is that it was her son who was her assailant when Sally had known he was unwell for some considerable time and had been trying to obtain help for him. At subsequent criminal trial, he was diagnosed by two psychiatrists with schizophrenia. He was Information Classification: CONTROLLED charged with murder but, given his diagnosis, the Crown accepted a plea of guilty to manslaughter on the grounds of diminished responsibility. has been made the subject of a hospital order pursuant to s37 MHA with a s41 restriction. He did not attend the inquest.
2) mental health difficulties were known. Indeed, as we shall hear, in June 2020, a year before Sally’s death, he had been detained under s2 of the MHA and spent 10 days or so as an in-patient at Longreach Hospital. After his discharge, was recognised by various members of his family, particularly Sally, to deteriorate still further. She tried repeatedly to persuade State agencies to help her son. The NHS England report (the Niche report) documents 23 specific requests to four different agencies from Sally for to be seen and have his mental health assessed and ten occasions when other family members requested help. Yet, at the time of her death, as a matter of fact, was not under the care of CPFT and had not been assessed by a doctor from the Trust for a year. Additionally, there had been four alerts to safeguarding but in the 13 months where was known to Adult Social Care, no one had actually seen him, face-to-face.
3) This inquest has been concerned to understand how Sally could have died in these circumstances. In addition to my written judgment, you may wish also to consider the independent NHS mental health review (the Niche report) and the forthcoming DHR, a final draft of which was made available to the Interested Persons.

Copies sent to

Penryn SurgeryCornwall Council

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2024-0267
Date of report: 14 May 2024
Coroner: Andrew Cox
Coroner area: Cornwall and the Isles of Scilly

Responses identified

Responses identified 2 of 4

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Jul 2024 (estimated).

Sent to

CIOS ICB

Cornwall Council

Cornwall & Isles of Scilly Integrated Care Board

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.