Martin Gibbons

Coroner's concerns

AI summary

A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led to inconsistent risk assessments. Prolonged mental health bed waits were also exacerbated by fragmented commissioning.

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1. During the course of the inquest evidence was heard that the acute and mental health trusts involved had assessed the level of risk he presented differently in part due to there being no shared definition of risk or the factors that triggered a patient being treated as high risk. The inquest heard that across the NHS there is in relation to mental health no shared definition between acute and mental health trusts of what constitutes a high risk patient. The two trusts involved in this inquest had since Mr Gibbon’s death identified that as an issue and work was underway between them to develop and implement a shared definition locally in the absence of any shared national definition.
2. The inquest heard evidence that since Mr Gibbon’s death both trusts had recognised that to reduce risk there needed to be detailed and documented shared risk assessments and care plans for patients such as him in an acute setting. The inquest heard that there was no national or regional guidance in place in relation to this shared care plan approach.
3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular

• A national lack of mental health beds;

• The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed. The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created.

Responses

2 respondents

GMCA Other

14 Jul 2021 PDF

Action Taken

Tameside and Glossop Integrated Care NHS Foundation Trust (TGICFT) and Pennine Care NHS Foundation Trust (PCFT) conducted a joint investigation and will present the learning to the Greater Manchester Quality Board and to commissioners of services to consider within the context of the services they commission. (AI summary)

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Dear Ms Mutch Re: Regulation 28 Report to Prevent Future Deaths – Martin Gibbons 24/03/2020 Thank you for your Regulation 28 Report dated 22/04/2021 concerning the sad death of Martin Gibbons on 24/03/2020. Firstly, I would like to express my deep condolences to Martin Gibbon’s family. The inquest concluded that Martin’s death was a result of 1a Hypovolaemic shock, 1b Neck laceration Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken. This letter addresses the issues that fall within the remit of GMHSCP and how we can share the learning from this case. Tameside and Glossop Integrated Care NHS Foundation Trust (TGICFT) and Pennine Care NHS Foundation Trust (PCFT) conducted a joint investigation following the tragic incident on 24 March 2020, allowing one point of contact for the family, and learning across both trusts. As an outcome of the investigation both trusts recognised the need to develop shared care principles and an agreed risk stratification/triage tool, including actions required should a person present to the emergency department (ED) who is considered a high risk to themselves. This document also needed to specify who is responsible for caring for the patient at given times when in the ED and include

escalation procedures as required. Additionally, it was acknowledged that a system to aid the communication and handover of clinical information between the two organisations was needed to be implemented. This included a handover sheet developed by both teams and increased access for the Liaison Mental Health Team’s (LMHT) access to the ED system. Further detail around how this work has developed is provided below:
• The LMHT has now completed a joint piece of work with their ED colleagues at TGICFT. A triage assessment tool has been implemented which guides the triage nurse to consider the most appropriate pathway for the patient based on their risk/presentation at that time.
• A joint risk assessment tool has now been implemented. This is initially completed by the triage nurse and guides them into rating the patient’s risk at that time in terms of high (red), medium (amber) and low (green). This then informs the level of observation required for the patient whilst in the ED.
• A mental health presentation engagement record is now in use. This is used to document the observation of the patient whilst they remain in the ED. Whilst the LMHT makes every effort to provide a staff member to complete these observations, due to service provision, this is not always possible. In these circumstances, an agreement is in place that this staff member will be provided by the ICFT.
• On assessment by the LMHT, the risk assessment is reviewed alongside a suicide risk screen being completed. The practitioner is then asked to rate the level of risk again using the same levels described above and agree an observation level for the patient. This joint working document then details the outcome of the assessment and the plan for the patient (inclusive of a plan should they be waiting for a bed in the ED) which is agreed and signed by the LMHT practitioner and the ED team leader. This evidences the handover and working plan for the patient. Additionally, both teams have a handover sheet in use. PCFT’s handover sheet requests the name of the ED practitioner that a handover has been given to.
• Whilst not an action arising from this incident, the service has also implemented a patient information leaflet which is provided to the patient at the point of the referral to the LMHT and details what they can expect from the team. This encourages those thinking about leaving the department to inform a member of staff who may be able to look at alternative support for the patient.
• A standard operating procedure is being embedded for both organisations to reflect the shared care principles. As noted in the Regulation 28 Mr Gibbons was assessed as needing admission for a period of assessment and possible treatment and an informal admission was agreed. A plan was put in place at this point to obtain a bed for Mr Gibbon’s and Bed Management in Manchester were notified as he was registered on the national spine with a GP in Trafford. Efforts were then made to source a bed for Mr Gibbons and the family were advised there could be a delay in doing this.

Trusts are commissioned to provide inpatient beds to people who are resident in the areas they serve. The inpatient stay is only part of the whole pathway of care that a

service user has during their time in the trust and providing effective and safe transition between parts of the system (e.g. on discharge or on leave/liaison with community services) is best done in an inpatient service as close to their own community as possible, particularly as different trusts use different clinical information systems and have different pathways of care. In some circumstances, where there may be a significant delay in a bed being available in another trust, the assessing trust may extraordinarily temporarily admit a patient. However, to do this regularly would incur other risks around transitions of care of an individual either during the acute stage of their illness or on discharge from hospital when they are supported by community teams who will not have been able to develop a relationship with the patient due to geographical distance.

There has been an overarching reduction in the mental health bed base capacity across the country over a number of years.This is having an ongoing impact in terms of local systems having the necessary capacity to meet the ever-increasing demand on services. In Greater Manchester we are investing significantly into our community and crisis services so that we have a holistic service offer, which will ensure that the demand on mental health beds is manageable.

Actions taken or being taken to prevent reoccurrence across Greater Manchester.

1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.

2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission.

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. GMHSCP is committed to improving outcomes for the population of Greater Manchester.

I hope this response provides the relevant assurances you require. 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.

Department of Health Social Care Central Government

8 Oct 2021 PDF

Action Planned

NHS England has asked all parts of the country to ensure that they have in place clear written protocols for escalation and actions to be taken when patients are waiting long periods, or a bed cannot be identified. (AI summary)

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Alison Mutch HM Senior Coroner Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG 08 October 2021 Thank you for your letter of 21 May 2021 related to the death of Martin Gibbons. I am replying in the capacity of a duty Minister, and am grateful for the additional time in which to do so. Firstly, I would like to say how saddened I was to read of the circumstances of Martin Gibbons’ death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, enquiries have been made with NHS England and NHS Improvement (NHSE/I) and their regional and local partners, and the Care Quality Commission (CQC). You raise a number of concerns in your report that I will address in turn. With regard to a shared definition of risk, evidence from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH)1, as well as National Institute for Health and 1 https://sites.manchester.ac.uk/ncish/reports/the-assessment-of-clinical-risk-in-mental-health- services/ From Maggie Throup MP Parliamentary Under Secretary of State for Vaccines and Public Health 39 Victoria Street London SW1H 0EU

Care Excellence2 guidance, suggests that risk assessments must not be seen as a form of a risk prediction. It is emphasised that whilst standardised tools may provide the impression of precision, they are poor in terms of prediction of suicide or a particular behaviour. Instead evidence suggests that assessments should be personalised according to individual circumstances.

Recently, (and in part due to concerns raised by your report) NHS England has asked all parts of the country to ensure that they have in place clear written protocols for escalation and actions to be taken when patients are waiting long periods, or a bed cannot be identified. The handover and management of a patient between services (in this case, acute and mental health services) is a local operational matter and the safety of these processes is the responsibility of the clinicians and operational managers involved in the direct care of the patient. There is a significant body of guidance that emphasises the importance of sharing patient information (which includes assessments and care plans) between clinical teams for the purposes of direct clinical care. National guidance3 on care for people with mental health needs in emergency departments has been published by NHS England. All hospitals should have a process for providing safe, dignified care for patients with mental health needs who wait for long periods.

I am pleased to note the actions that the Tameside and Glossop Integrated Care NHS Foundation Trust and the Pennine Care NHS Foundation Trust have taken to improve local communication and handover processes and to clarify responsibilities in relation to a person presenting to the emergency department who is considered a high risk to themselves.

The provision of 24/7 liaison psychiatry has consistently been highlighted as the priority action by NCISH and through a special report by the Healthcare Safety Improvement Board (HSIB) to improve safety for mental health patients in emergency departments. We have through the Five Year Forward for Mental Health (2016) invested £249million in liaison psychiatry, to provide specialist mental health assessment and treatment. Through the NHS Long Term Plan, we are providing an additional £58million funding by 2023/24.

All acute hospitals now have an adult liaison service in place, with 78 per cent of these services operating 24 hours a day, 7 days-a-week, which is an increase from 39 per cent in 2017, and this expansion is continuing through the NHS Long Term Plan. NHSE/I is working with local areas to design and implement care pathways that are integrated with the wider health and social care system, including timely sharing of information between liaison psychiatry teams and community mental health services.

I have noted your concerns about the time taken to identify and confirm a mental health bed for Mr Gibbons. The provision of mental health beds is determined by local NHS commissioners, taking into consideration local need as well as the effectiveness of the local mental health system in providing access to care and support to people in the community, thereby reducing the requirement for admission to hospital. While in some local areas there may be a genuine need for more inpatient capacity, this should always be considered as part of whole system transformation to reduce over reliance on hospital-based care. The NHS Long Term Plan (LTP) will provide an additional £2.3billion a year invested into mental health services by 2023/24, approximately £1.3billion of which relates toadult community, crisis and acute mental health services in order to provide quicker access to care, and prevent avoidable deterioration and hospital admission.

2 National Institute for Health and Care Excellence 3 https://www.england.nhs.uk/wp-content/uploads/2016/11/lmhs-guidance.pdf

You may also wish to note that, while we are emerging from the crisis period resulting from COVID-19, we continue to monitor the impact of the pandemic and adjust policy and investment priorities where necessary. The NHS will be investing significantly in mental health service capacity this year, with an additional £500million in 2021/22 to support recovery in mental health services on top of the funding already committed through the NHS Long Term Plan. This investment includes funding to bring forward existing plans to improve/expand community mental health services, crisis care services and support for people to be discharged from hospital in a timely manner. All of which should help to both reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.

In relation to local commissioning arrangements, it is usually the case that the closest hospital to where the patient is resident will provide the most effective and best experience of care for that individual, ensuring strong continuity of care at admission and discharge and helping to maintain connection with support networks.

There may be a small number of circumstances where it might be appropriate for a patient to be admitted to a hospital which is further away from where they live. For example, emergency admissions whilst away from home, safeguarding concerns, or where patient choice is exercised. Clinical consideration should always be given as to where it is best to admit someone, taking individual needs into account and not based solely on how services are commissioned in an emergency situation.

Finally, reducing suicide and preventing self-harm remains a key priority for the Government.

We are investing an additional £57million in suicide prevention by 2023/24 through the NHS Long Term Plan. This will see investment in all areas of the country to support local suicide prevention plans and the development of suicide bereavement services. In addition to this, we are also providing an extra £5million in 2021/22, to be made available specifically to support suicide prevention voluntary and community sector organisations.

In March 2021, we published the latest progress report against the National Suicide Prevention Strategy and, within this, a refreshed cross-government suicide prevention workplan. This sets out a comprehensive and ambitious programme of work across national and local Government, and delivery partners, which sets the framework for how we intend to reduce suicides in England.

I hope this response is helpful.

MAGGIE THROUP MP

Report sections

Investigation and inquest

On 25th March 2020 I commenced an investigation into the death of Martin Gibbons. The investigation concluded on the 22nd April 2021 and the conclusion was one of suicide. The medical cause of death was 1a Hypovolaemic shock, 1b Neck laceration

Circumstances of the death

Martin Anthony Gibbons attempted to take his own life on the morning of 19th March 2020. He had at times in the days previously displayed symptoms consistent with a deterioration in his mental health. He was taken to Tameside General Hospital. He was assessed as requiring treatment for the wounds he had inflicted on his arms with a knife and assessment by the mental health liaison team. The assessment by the mental health liaison team identified he needed to be admitted to a psychiatric ward. He agreed to that and had he not agreed the mental health team would have sought to section him under the Mental Health Act. He was left at Tameside General Hospital in the designated mental health room whilst a bed was sought for him. At the time he was left there was a failure to conduct a detailed risk assessment for the period whilst a bed was sought or to agree a joint plan to manage the risk. It is probable that failure contributed to his death. Martin Gibbons left room 14 saying he was going to the toilet. Whilst unobserved he left the hospital. He purchased a Stanley knife just over an hour later in Stalybridge. A full search by Tameside General Hospital staff and Greater Manchester Police was unsuccessful until 24th March 2020.

On 24th March 2020 he was found in a secluded area of Stamford Golf Course. There were no suspicious circumstances and no evidence of third party involvement in his death. Post mortem examination confirmed he was not under the influence of any substance at the time of his death and that he had died from a self-inflicted neck laceration.

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