Source · Prevention of Future Deaths

Oliver Beswetherick

Ref: 2024-0097 Date: 21 Feb 2024 Coroner: Julian Morris Area: London Inner (South) Responses identified: 1 / 1 View PDF

Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading to repeated patient assessments and delayed urgent support.

Date 21 Feb 2024

56-day deadline 17 Apr 2024 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading to repeated patient assessments and delayed urgent support.

View full coroner's concerns

(1) It became evidence during the inquest that CMHT/ Crisis teams do not have contact details of: (i) Psychiatric liaison nurse services in neighbouring (out of their locality) boroughs based in Accident & Emergency departments, or details of (ii) CMHT/ crisis teams in neighbouring boroughs.

Such contact could provide for direct referral, contact and passing on of knowledge of cases between neighbouring organisations, especially when individuals have already been assessed and asked to attend for a face-to-face consultation. Otherwise, those individuals who seek help, may have to revisit the same process of being interviewed on multiple occasions with a sense of déjà vu and anxiety that they are not obtaining the urgent assistance and support that they require. That may lead to them not engaging when they had hitherto made every attempt to do so.

To provide those contact details would seem a relatively simple task, so teams could contact each other, and the local psychiatric liaison nurses based within the A&Es.

Responses

1 respondent

NHS England NHS / Health Body

21 Feb 2024 PDF

Noted

NHS England states that all NHS services have access to the 'Service Finder Tool' which offers health and social care professionals accurate and up-to-date information, including contact details. It also notes the NHS Long Term Plan recognised the crucial role of community mental health services. (AI summary)

View full response

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Oliver Beswetherick who died on 4 September 2020.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 February 2024 concerning the death of Oliver Beswetherick on 4 September 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Oliver’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Oliver’s care have been listened to and reflected upon. 

Your Report raises the concern that Community Mental Health and Crisis Teams do not have the contact details of Psychiatric Liaison, Community Mental Health, and Crisis Teams within neighbouring boroughs.

All NHS services have access to the ‘Service Finder Tool’ which offers health and social care professionals accurate and up to date information on available services within a specific locality through a mobile-friendly interface that is quick and easy to use. It is primarily aimed at healthcare professionals who already have a care pathway in mind. Through NHS Service Finder, health and social care professionals can access a variety of service information, including comprehensive contact details, eligibility criteria, and referral instructions. Maps and directions to the services are also available, and public service information can be emailed directly to a patient. Additionally, the NHS website has a directory which indicates the nearest mental health crisis line to a person’s postcode. This also allows clinicians to make the referral to the appropriate service or direct the patient/clinician for next steps. The NHS Long Term Plan (LTP) recognised the crucial role of community mental health services and committed almost £1bn extra per year by 2023/24 to transform and expand the provision of community mental health services for adults and older adults with severe mental illness.

Since 2021, all areas have received significant additional funding to develop these new integrated models of primary and community mental health services, based around Primary Care Networks (PCNs). Services should adopt a ‘no wrong door’ approach to ensure people don’t get lost in the gaps between services. Services should be easy to access, flexible, tailored to individuals whole-life needs and National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

09 May 2024

delivered as close to home as possible. Continuing to expand and embed the transformation of community mental health services remains a priority.

I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Report sections

Investigation and inquest

On 27 November 2020 I commenced an investigation into the death of Mr Oliver Beswetherick, aged 24 years. The investigation concluded at the end of the inquest on 11 December 2023. The conclusion of the inquest was a narrative conclusion.

Circumstances of the death

Mr Beswetherick had suffered from depression and bulimia, since 2015 and 2018 respectively. During 2019 – 2020 he was seen regularly by a therapist and consultant psychiatrist, the latter confirming the diagnosis of bipolar affective disorder type II for which he prescribed medical treatment. Up until 22 August 2020, Mr Beswetherick was well. On 29 August he attended A&E and was seen by the psychiatric liaison nurse, who, after assessing him wrote to his consultant, whom he was due to see a couple of days later. That review took place on 31 August and the consultant immediately referred Mr Beswetherick back to his GP for urgent referral to the CMTH/ crisis teams. Mr Beswetherick and his partner sought updates from the practice over the following days, 1-3 September 2023. On 3 September, following further discussions about Mr Beswetherick’s suicidal nature, he was referred by his GP to the CMHT. Their assessment was that he should be seen face to face. However, Mr Beswetherick had moved out of the local catchment area (East London) to south of the river (Southwark). He was therefore advised to attend his local A&E to see the local psychiatric liaison nurse who would be able to refer into the local services. No direct referral to the either the psychiatric liaison nurse or local services was made.

On the morning of 4 September 2020, Mr Beswetherick was identified, having fallen from his flat to the ground. He was pronounced dead at the scene by LAS, the MPS deeming the scene non-suspicious. A note was found.

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Shared signals

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Report details

Reference: 2024-0097
Date of report: 21 February 2024
Coroner: Julian Morris
Coroner area: London Inner (South)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Apr 2024 (estimated).

Sent to

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.