Source · Prevention of Future Deaths

Odichukwumma Igweani

Ref: 2023-0296 Date: 16 Aug 2023 Coroner: Sean Cummings Area: Milton Keynes Responses identified: 3 / 3 View PDF

A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment and care, despite their obvious deteriorating condition.

Date 16 Aug 2023

56-day deadline 1 Nov 2023 est.

Responses identified 3 of 3

Mental Health related deaths

Coroner's concerns

AI summary

A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment and care, despite their obvious deteriorating condition.

View full coroner's concerns

Out of hours and emergency mental health care for people who are not registered with an NHS GP in Milton Keynes may be obtained by attending the Emergency Department at the Milton Keynes University Hospital where mental health professionals are based. Through Kelvin's period of deteriorating mental health, which was obvious to those who knew him, his mother made repeated attempts to secure mental health assessment and care for him. She was not directed clearly by the professionals she did have contact with, to take him to the Emergency Department for assistance. There was a gap which Kelvin fell through and he did not receive either mental health assessment or care. It was not possible to say that the failure to receive assessment or care resulted in Kelvin attempting to take the lives of others and succeeding in taking the life of his male neighbour. It was clear that the lack of clear information and direction in regard to how to obtain that mental health assessment or care contributed to Kelvin not presenting for assessment which may possibly have averted the tragic events which unfolded on the 26th June 2021. This in turn raises the prospect that others, in similar predicaments may also be unable to obtain the care required.

Responses

3 respondents

Bedfordshire Luton and Milton Keynes Integrated Care Board Integrated Care Board

16 Aug 2023 PDF

Action Planned

The ICB will work with primary care practices to ensure patients declined registration receive details on how to find and register with a GP and ensure practices are aware of the mental health single point of access. They will also work with CNWL to ensure mental health crisis information is available in surgery waiting areas and continue to work with 111 providers on the dedicated process for mental health due in Spring 2024. (AI summary)

View full response

Dear Mr Cummings

Re: Regulation 28: Report to prevent future deaths

Thank you for the Regulation 28 report dated 16th August 2023 following the inquest into the death of Mr Kelvin Igweani. I am writing to provide Bedfordshire Luton & Milton Keynes Integrated Care Board (BLMK ICB)’s response to the concerns raised in the inquest report.

Firstly, BLMK ICB would like to extend our sincere condolences to Mr Igweani’s family and friends.

The matters of concern raised in the regulation 28 report to prevent future deaths are as follows:

Out of hours and emergency mental health care for people who are not registered with an NHS GP in Milton Keynes may be obtained by attending the Emergency Department at the Milton Keynes University Hospital where mental health professionals are based. Through Kelvin's period of deteriorating mental health, which was obvious to those who knew him, his mother made repeated attempts to secure mental health assessment and care for him. Kelvin’s mother was not directed clearly by the professionals she did have contact with, to take him to the Emergency Department for assistance. There was a gap which Kelvin fell through and he did not receive either mental health assessment or care. It was not possible to say that the failure to receive assessment or care resulted in Kelvin attempting to take the lives of others and succeeding in taking the life of his male neighbour.

It was clear that the lack of clear information and direction in regard to how to obtain that mental health assessment or care contributed to Kelvin not presenting for assessment which may possibly have averted the tragic events which unfolded on the 26th June
2021.This in turn raises the prospect that others, in similar predicaments may also be unable to obtain the care required. Medical Directorate BLMK ICB Priory House Monks Walk, Chicksands Shefford Bedfordshire SG17 5TQ 15th February 2023 Mr Sean Cummings Assistant Coroner for Milton Keynes BY EMAIL ONLY

BLMK ICB acknowledge the concerns raised and have worked with our providers to look at pathways and to understand where learning is needed to ensure that others, in similar situations, can access appropriate care as required.

We will work with our primary care practices across BLMK to ensure that when patients are declined registration, which is appropriate as part of their contract such as with boundary limitations, the practices are able to share appropriate details on how to find and register with a GP practice such as through NHS Choices or through the ICB

Find a GP - NHS (www.nhs.uk) Contact us - Bedfordshire, Luton and Milton Keynes Integrated Care Board (icb.nhs.uk)

Through our primary care forums, weekly bulletins and working with Central and North West London (CNWL), we will ensure that practices in Milton Keynes are aware of the mental health single point of access which is a 24 hour and 7 day a week service, that gives advice on how to access local mental health services and can be accessed via email and/or by telephone.

We will work with CNWL to ensure that information regarding mental health crisis is available in surgery waiting areas across Milton Keynes. Will we extend this to our other mental health providers across BLMK to ensure crisis information is readily available in all BLMK primary care practices.

We will continue to work with our 111 providers with regards to the implementation of the dedicated process for mental health due to come into affect in Spring 2024.

These work streams will be reported through our Primary Care Delivery Group and System Quality Group. Thank you for bringing the concerns to our attention, we hope this response provides both yourself and the family of Mr Igweani with assurance that BLMK ICB takes these concerns seriously and are committed to ensure that improvements are made across our systems. However, should you have any further queries or concerns please do not hesitate to contact me.

Kind Regards

Chief Medical Director | BLMK Integrated Care System

Red House Surgery

25 Sep 2023 PDF

Noted

Red House Surgery states it was unable to register the patient due to their address being outside the practice catchment area, and this is practice policy. They assert they provided the mother with the number for the crisis centre, which is practice policy for anyone raising a mental health concern who cannot access a GP. (AI summary)

View full response

Dear Sir/Madam REGULATION 28: REPORT TO PREVENT FUTURE DEATHS Further to your request for information regarding regulation 28 report to prevent deaths we can confirm that we provided information to the coroner regarding the reasons why Red House Surgery were unable to register Odichukwumma Kelvin Igweani at the Red House Surgery around the 16th of June 2021 . (Please see attached copy) Regarding the comments posed in your report we can confirm that barrister informed our Practice Manager while she was attending as a witness, that she had contacted the surgery one evening to request that her son be registered at the practice. At the time she arrived the surgery had closed, which would indicate that this was after 6.30pm. However, staff were still on site and so opened the door to speak with to and she requested that her son be registered at the practice. The staff asked for his address and due to this being given as Oldbrook, she was advised that this is outside of our practice catchment area, and we would, therefore, be unable to register her son. This information is correct and practice policy. The barrister also informed the Manager that had informed staff that she was worried about her son's mental health, and she was therefore, given the number for the crisis centre by a member of our practice team. Again, this is practice policy for anyone who raises a mental health concern and cannot access a GP at that time, whether a registered patient or not. 16th We can confirm that on the of June emailed the practice asking if her son could re-register at the practice. She explained that her son had de-registered himself. Patients are automatically removed from a surgery list when they register themselves with a new GP practice. We are not aware if he had registered at a local to Milton Keynes but can confirm that he was deregistered from the practice on the 23rd ofNovember 2019. ·

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25.9.23 Report to prevent future deaths In the email (copy attached) informs the practice that her son has been "suffering from his mental health for a very long time but has so far refused any sort of help". She states he is now open to seeing someone and so wishes for him to be registered at Red House Surgery. She also states that they have just gone through a distressing few months since the 9th of March with Kelvin going AWOL for long periods and the police being involved as he had been reported missing. An email response was sent to on the 21st of June, explaining that the request had been discussed at the practice but due to the policy ofnot accepting patients who do not live within the practice catchment, the request to register was refused. We appreciate the comments made by the coroner that action should be taken to prevent future deaths but as discussed at the investigation the following had been undertaken. Staff had informed that it would not be possible to register her son at The Red House Surgery. Looking at the email from this appears to have been on the 16th ofJune 2021. by her own admission had been given the number of the crisis team by the practice staff at this time. We have no knowledge as to whether contacted the crisis team. then emailed the practice with the same request on the 16th ofJune and received a response on the 21 st ofJune 2022. Had requested help in finding an alternative practice where her son could register, we could have been able to provide the contact details of the then Clinical Commissioning Group (CCG) who would be able to provide details oflocal GP surgeries. There are 26 practices within Milton Keynes, but we are not aware oftheir individual catchment areas. It should be noted that had said her son was living in Oldbrook at the time, however, the coroner's report stated that he was resident with his partner at 74 Denmead, Two Mile Ash and so it would have been appropriate for him to register with a GP surgery who looks after that estate/area. This area is also not within our catchment. It could be presumed that his partner and children were registered with a local GP and could therefore, have joined the same practice as them.

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25.9.23 Report to prevent future deaths We continue to instruct our staff that anyone who raises concerns that they have a mental health crisis are provided with the telephone number for the crisis centre. We have produced both a text message and a paper slip to give to patients with different organisations to contact for support, copy attached. We do have a Duty doctor of the day and wherever possible the duty doctor is informed ofany patient who either states or appears to be in a mental health crisis. However, should a GP not be available for any reason or in an event such as this when the staff are on site, but out of core hours, without GP support they should offer the crisis number to the person involved. It may well have been helpful to provide with the crisis number again in the email response and the contact details of the CCG, now the BLMK Integrated Health Board (ICB) to assist with finding an alternative practice and this will be considered for future responses. It should be remembered that practice staff are not responsible for recommending GP practices to patients and that it is patient choice as to which surgery they wish to register with, dependent on their catchment area. Staff are also not familiar with catchment areas for individual practices. Our policy if asked, is to suggest an internet search or to ask neighbours, people in the locality or to contact the BLMKICB. This event has been discussed several times at GP meetings with a view to any learning outcomes and staff have been made aware of the need to be vigilant if anyone they encounter raises concerns about their mental health or that of another person. We will further discuss this event at a future protected learning session and ensure that all staff are reminded about the crisis team and contact numbers for other support organisations and should GP interaction not be possible to refer anyone at risk to attend A&E. We will ensure that all new staff as part of their induction, are informed of the need to be aware ofpatients who may be in a mental health crisis and the relevant steps to be taken.

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25.9.23 Report to prevent future deaths We remain unable to accept the registration of any patients who do not live within our catchment area. Our catchment area has been set up with the approval ofthe now ICB and we have been instructed that acceptance ofany one from outside our catchment will make us liable to accept all patients from that area. The curtailment of our practice catchment area took place in 2003 and many outlying patients were asked to register with an alternative practice closer to their home address. Due to issues within MK around this time, some practices were struggling with capacity, and we were asked to halt this process. It is for this reason that we still have some outliers registered with our surgery. Had we been able to continue with our catchment area programme, the Igweani family would have been asked to register at an alternative practice. There are many drawbacks to having patients registered out-side ofthe catchment: -
• Difficulty in attending for appointments.
• Excessive time for doctors and paramedics on home visits
• Delayed time in getting to visit an unwell patient.
• Patients under the care of district nurse/health visiting team are often referred to an alternative team which does not help with interaction with the referring GP. We hope this information is helpful but please do not hesitate to contact us if you require any further information. With kind regards Yours faithfully GP Partners ofRed House Surgery Encs:
• Original report to Coroner
• Emails exchange re request to register from Mrs Igweani-Gilmartin / Jane Hanlon
• Handout ofwhere to obtain support when in mental health crisis.

RED HOUSE SURGERY 241 QUEENSWAY BLETCHLEY MILTON KEYNES MK22EH

31.3.2022 Coroners Officer Dear Sir/Madam RED HOUSE SURGERY - Catchment Area Policy This is to confirm the policy of The Red House Surgery not to accept new patients who do not have a home address that falls within our catchment area. Historically Red House Surgery had a large catchment area but a considerable number of years (2003) ago with the approval of the then Primary Care Trust (PCT) it was agreed that we could change our catchment area and over a period of time we contacted patients living outside our catchment and requested that they change surgeries. This was an extensive piece of work but was necessary in order that we could accommodate all the new builds and additional population within the Bletchley area. The surgery premises are a converted house and space is extremely limited. We are unable to extend the site to enable us to take on further clinicians to accommodate an expansion to our practice list size. Another main reasons for this decision was that it was very difficult for GPs to visit patients within a timely manner if a home visit was required. The GPs raised this as a concern as had on occasion visited unfamiliar estates/areas at the end of evening surgery and found that patients would have benefitted from a visit earlier in the day but this hadn't been possible due to the distance from the surgery and the number of visits spread across the MK area. This they felt offered a sub-standard service to their patients. A further issue arose with patients requiring the services of District Nurses and midwives in particular as they have strict areas and have to organise for patients to be seen by other teams which can create problems with the teams not linking with the GP practice where the patient is registered. It was therefore, agreed that our policy would be to, not accept any new patients or change of address detai Is for existing patients to any areas outside of our practice catchment. We have a core practice area for any new patients and an extended area for those existing patients who move outside our core catchment area. See attached I ist. As you will see Oldbrook does not fall within our core or extended area.

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31.3.22 Coroners Officer We agreed that there would be some patients who remained registered with us whose address was out of catchment but decided to accept these and would allow them to remain registered with us until such time as they moved from the area or perhaps decided to move to a practice closer to their home. We were informed by the PCT at the time that we are unable to make exceptions to our policy as by accepting any new patient from an area would make us liable to accept all requesting patients from that area. We have made an odd exception to keep a patient registered for a short length of time (approx. 3 months) but these have been patients who are terminally ill and at end of life and a few pregnant ladies who were close to the end of their pregnancy who we kept until they gave birth and they and their new born then registered with doctor in their new area. With regard to case that you are currently involved with (Kl) I can confirm that his mother emailed the practice on the 16th June asking if her son could re-register at the practice. She explained that her son had de-registered himself. This would imply that he had registered at an alternative practice. She said she had been informed by the practice staff that this would not be possible as he would be considered a new patient and as Oldbrook is outside our catchment area we would be unable to accept him. However, as she subsequently emailed in, her request was raised with the GP Partners who agreed that they were unable to make an exception to the practice policy and a response email was sent explaining this. I hope this information is helpful but please do not hesitate to contact me if you require any further information,

With kind regards

Central and North West London NHS Foundation Trust NHS / Health Body

3 Oct 2023 PDF

Action Planned

CNWL will discuss the case in a Care Quality Improvement Forum meeting, cascade a learning leaflet to local GPs via the Primary Care Network (PCN) alliance, and supply posters to GP surgeries with information on how to access mental health services via the ED at MKUH. Nationally, NHS England are working with NHS 111 to create a dedicated process to access MH services due in April 2024. (AI summary)

View full response

Dear Mr Cummings, Re: Regulation 28: Report to prevent future deaths Thank you for your Regulation 28 report dated 16 August 2023 following the inquest into the death of Mr Kevin Igweani. I am writing to provide Central and North West London NHS Foundation Trust (CNWL)’s response to the concerns that you raised in that report. Firstly, we would very much like to extend our condolences to Mr Igweani’s family and friends. The matters of concern that you raised were: Out of hours and emergency mental health care for people who are not registered with an NHS GP in MK may be obtained by attending the ED at the MKUH where mental health professionals are based. Through Kelvin’s period of deteriorating mental health which was obvious to those who knew him, his mother made repeated attempts to secure mental health assessment and care for him. She was not directed clearly by the professionals she had contact with to take him to the emergency department for assistance. There was a gap which Kelvin fell through and he did not receive either mental health assessment or care. It was not possible to say that the failure to receive assessment or care resulted in Kelvin attempting to take the lives of others and succeeding in taking the life of his male neighbour. It was clear that the lack of clear information and direction in regard to how to obtain that mental health assessment or care contributed to Kelvin not

presenting for assessment which may possibly have averted the tragic events which unfolded on the 26th June 2021. This in turn raises the prospect that others, in similar predicaments may also be unable to obtain the care required. We acknowledge your concerns and confirm that we have reviewed the information available on our website. This advises that urgent mental health support can be provided via our Single Point of Access service (SPA) 24 hours a day, 7 days a week which is accessible on telephone number: The Single Point of Access gives advice on how to access local mental health services in Milton Keynes, this may include going to A&E. Nationally, NHS England are working with NHS 111 to create a dedicated process to access MH services. This will mean that if a member of the public calls 111 with a MH concern they will automatically be diverted to the MH Crisis Lines which exist nationally. This is due to come into effect in April 2024. We will discuss this case in our Care Quality Improvement Forum meeting planned for 23 October. These meetings are attended by representatives from all of our Mental Health teams, and then further through their team business meetings which are held weekly. We will also cascade a learning leaflet to local GPs via the Primary Care Network (PCN) alliance that we attend jointly with representatives from our local GPs and we will supply posters to GP surgeries to be displayed in their waiting areas informing how those presenting with acute mental health crisis can access mental health services via the ED at MKUH. Thank you for bringing your concerns to our attention. We hope that this response provides some reassurance to both you and to Mr Igweani’s family that the Trust has taken the matters raised seriously. Should you have any further questions or concerns, please do not hesitate to contact me.

Report sections

Investigation and inquest

On 01 July 2021 I commenced an investigation into the death of Odichukwumma Kelvin IGWEANI aged 24. The investigation concluded at the end of the inquest on 19 April 2023. The conclusion of the inquest was that he was lawfully killed.

Circumstances of the death

At the time of the incident Kelvin Igweani was living at

. Prior to the incident on the 26th June 2021 evidence shows Kelvin was suffering undiagnosed mental health problems, which were deteriorating over several months. Attempts by Kelvin’s mother to secure mental health assistance for him were unsuccessful, as no formal assessments were made. His mental health then spiralled significantly in the four days proceeding the incident. On the morning of 26th June 2021, Kelvin became extremely violent, firstly trying to forcefully baptise his partner’s children in the bath. His partner and her daughter were able to flee to knock on the neighbours flat ( ) to seek assistance to call the police. His partner was then dragged back . Kelvin then forcefully regained control of her two year old son and began to progress into holding him under water causing him to become unconscious. On a second successful attempt to flee to the neighbours flat ( ), his partner and her daughter asked the neighbours to help save her son as Kelvin was trying to kill him. The neighbour then went into to try and save the two year old boy but was bludgeoned to death . The neighbours called the police and gave shelter to Kelvin’s partner and her daughter. At this point, the first officer on scene attempted to gain entry after announcing she was police but was unsuccessful, so called for back-up assistance with method of entry equipment. The police arrived and forced entry into the flat. Kelvin was tasered ineffectively at the front door of the flat and retreated into the bedroom where he barricaded himself in with the two year old boy. Armed police forced entry into the bedroom after repeated unsuccessful attempted to secure the childs release and on hearing sounds of someone being beaten in the bedroom. At no point did Kelvin engage or respond to the police requests to cooperate. Kelvin sprung out of the wardrobe and lunged forward once the bedroom door had been taken down by police. The police discharged four shots and two of them hit Kelvin in the chest. Kelvin died from gunshot wounds. The evidence shows Kelvin suffered from a severe mental health episode leading to and at the time of the incident for which he was unable to access adequate mental health care and attention. No mental health input or care received, as there was no engagement with A&E, crisis team or any other mental health services.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2023-0296
Date of report: 16 August 2023
Coroner: Sean Cummings
Coroner area: Milton Keynes

Responses identified

Responses identified 3 of 3

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Nov 2023 (estimated).

Sent to

BLMK Integrated Care Board

North West London NHS Foundation Trust

Red House Surgery

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.