Source · Prevention of Future Deaths

Louise Allen

Ref: 2022-0159 Coroner: Nadia Persuad Area: East London Responses identified: 1 / 5 View PDF

An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care co-ordinators facing high caseloads and staff turnover.

Responses identified 1 of 5
Mental Health related deaths Railway related deaths Suicide (from 2015)

Coroner's concerns

AI summary
An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care co-ordinators facing high caseloads and staff turnover.
View full coroner's concerns
Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:

1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.

Responses

1 respondent
NHS Foundation Trust
PDF
Action Planned

The Trust is continuously recruiting temporary staff and plans a Quality Summit to redesign services based on demand and need. They are also recruiting 8 additional Band 6 Community Psychiatric Nurses and will review resource and staffing levels. (AI summary)

View full response
Dear Madam

Re: Inquest touching upon the death of Louise ALLEN

I refer to your letter dated 18 July 2022 and the enclosed Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.

Concerns

At the conclusion of the hearing into the death of Louise Allen, you expressed concern on the matters below:

1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.

2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.

3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.

4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.

5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.

Acting Chair:

Acting Chief Executive:

We have taken the following actions in relation to your concerns:

Need for better continuity of care, not enough care co-ordinators to ensure continuity of care is provided, and high turnover of staff.

The service continuously recruits temporary staff, through the Trust’s temporary staffing service until all positions are permanently recruited to.

Temporary staffing has been advised to prioritise Mental Health posts and to use off-framework agencies to support retaining locum support, and consistency to manage short term vacancies.

A NELFT training programme has been developed for band 5 staff to help them develop the skills and competencies to take up the role of care coordinator at band 6 level. This will constitute an intensive and supportive career development programme designed to attract recently qualified staff who have the potential to progress rapidly and will also help with staff retention in the community recovery service.

The trust has invested 2.5 million pounds to support Nursing, Allied Health Professions and Psychological Professions recruitment initiatives which includes international recruitment.

Efforts to make the post of care co-ordinator more attractive, and that pay at NELFT is at least comparable to other NHS Trusts.

NELFT has programmes in place to encourage staff to work in the organisation; the Trust has used non-recurrent funding to recruit additional staff to manage the real time increase of referrals and acuity of patients, following the pandemic. All new starters’ salaries are matched to their previous employment, so they do not lose out on their pay when they join NELFT. There is also a staff wellbeing service in place which is available to substantive and locum staff. In addition, the Trust is working to understand how staff can be supported through cost-of-living issues.

The Trust is undertaking a programme of mental health transformation, which once fully implemented will enhance the service offered to patients. Peer support workers have been given additional roles, with a focus on enhanced training in order that they can share their lived experiences with patients they manage. The Trust is re-designing care coordinator posts to increase the support available for professional development. Furthermore, the Trust continues to use Trust-wide work streams to have a zero-nursing vacancy; to use rolling advertisements to recruit and retain staff; utilise international recruitment to attract more professionals to work at NELFT; and to consider the use of financial incentives to attract and retain staff.

Reducing the case loads of care coordinators, to ensure they are not excessive.

A recent quality audit of staff caseloads carried out on 19 July 2022 showed a reduction in care coordinator caseload from 27-30 patients per care coordinator to 19-27 patients. There is a further audit planned on 19 August 2022 to review the caseload numbers per care coordinator

In the meantime, the Trust is introducing a Management and Supervision Tool (MaST) to support staff and their managers to ensure care coordinator caseloads are manageable and that appropriate supervision and support are in place; this is anticipated to be fully operational by December 2022.

No commensurate increase in number of care coordinators to match the increased number of referrals to the service.

Acting Chair:

Acting Chief Executive:

A Quality Summit for the Waltham Forest Community Recovery Team was launched in July
2022.The purpose of the summit was to agree key quality priorities to improve patient/staff safety and quality of service delivery in the Waltham Forest Directorate. The focus will be on mental health services following feedback from Coroner Regulation 28 reports and learning from Serious Incidents. It is expected that actions will be developed and implemented and will include service re-design based on the level of demand and need, following the Quality Summit. Recommendations from staff and service users will inform the actions to be taken.

Trust-wide initiatives will also be considered, including system wide consultation within the NE London Integrated Care System to strategically consider the needs of the population and the associated risks.

Despite over-recruitment of care coordinators in financial budgets, the service is under- recruited in terms number of care coordinators.

The community mental health transformation programme will provide a better skill mix that will reduce the pressure on the care coordinator role. 8 additional Band 6 Community Psychiatric Nurses are being recruited to meet increased workload.

The NELFT Waltham Forest leadership team continuously reviews the needs and risk of the service. Additional staff will continue to be placed in the service to manage the need and risk, efforts are made at Trust executive and North East London system wide level to review the resource and staffing levels deployed into the service.

I would like to take this opportunity to thank you for raising your concerns as part of this inquest. We find learning from inquests extremely valuable and are very grateful for your comprehensive investigation, which benefits not only the families of the deceased, but also the Trust and its service users.

I trust that the above and the attached action plan will reassure you that the Trust has taken this tragic death very seriously indeed, and that it reflects our commitment to improve care quality and patient safety.

If I can further assist, please do contact my office on

Report sections

Investigation and inquest
On 24th June 2021 I commenced an investigation into the death of Louise Asha Allen, aged 41 years old. The investigation concluded at the end of the inquest on the 5th July 2022. The conclusion of the inquest was a narrative conclusion: Louise Allen took her own life whilst suffering from a mental health disorder. She was recognised as a very high risk to self, but in the months leading up to her death she did not receive the care that was necessary to protect her from the high risk with which she presented.
Circumstances of the death
Louise Allen suffered from bipolar disorder and emotionally unstable personality disorder. She was discharged from hospital following a lengthy admission to hospital in mid-December 2020. She was regarded as a very high risk to self and she required a careful and comprehensive community care-plan. Between February 2021 to June 2021 she did not receive the necessary mental state assessments by her care-co-ordinator; there was no additional support provided to engage her in activities to assist in promoting her recovery. In addition, inaccurate clinical details were on occasion presented to the multi-disciplinary team, resulting in unreliable risk assessments. On the evening of the 12th June 2021 Louise travelled to where she placed herself in front of a train.

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Report details

Reference
2022-0159
Coroner
Nadia Persuad
Coroner area
East London

Responses identified

Responses identified 1 of 5
4 responses not yet linked

Sent to

London Borough of Waltham Forest
North East London Health and Car
North East London Health and Care Partnership
TNW Integrated Care Partnership
North East London NHS Foundation Trust and The Clinical Commissioning Group

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