Source · Prevention of Future Deaths

Sharon Kelly

Ref: 2020-0250 Date: 24 Nov 2020 Coroner: Caroline Beasley-Murray Area: Essex Responses identified: 1 / 3 View PDF

Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental health crisis risks, including police attendance and urgent mental health assessments.

Date 24 Nov 2020

56-day deadline 8 Jan 2021

Responses identified 1 of 3

Emergency services related deaths (2019 onwards) Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

• Whether there is sufficiently clear training at EEASin relation to (1) identifying relevant flag markers to ensure police attendance ata property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
• Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019)
• Whether there is sufficient clarity in the training for Essex Police Comms Officers as to the circumstances in which a blue lights response should be mandated (in light of the evidence of Insp as to the response on 27 June 2019)
• Whether EPUT can review its arrangements for convening an urgent MHS assessment, in conjunction with social services. (in light of the jury’s findings with regard to the MHA assessment in June 2019)

Responses

1 respondent

EPUT NHS / Health Body

15 Dec 2020 PDF

Action Planned

The Trust will ensure referrals for urgent MHA assessments are accompanied by a telephone conversation, risks will be made explicit, and the timing of the MHA assessment will be explored with the referrer to agree/mitigate risk. (AI summary)

View full response

Dear Mrs Beasley-Murray,

I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 25th November 2020, which was issued following the inquest into the death of Sharon Kelly.

I would like to begin by extending my deepest condolences to the family of Ms Kelly. This has been an extremely difficult time for them and I hope that my response provides the family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issue of concern raised in your report.

In response to the matter of concern regarding whether EPUT can review its arrangements for convening urgent Mental Health Act Assessments in conjunction with social services, I can confirm that a strong collaborative relationship exists between EPUT and ECC which reflects, develops and undertakes continuous improvement initiatives.

In response to your concern, the Trust’s Associate Director for Social Care and the ECC Service Manager for Mental Health have jointly reviewed the current processes and have identified the following actions to be implemented by the Trust:

1. The Trust will ensure that referrals for urgent MHA assessments are accompanied by a telephone conversation between the referrer and the Emergency Duty Service (out of hours) and the Approved Mental Health Professional (AMHP) hub.
2. Risks indicated by the referral will be made explicit in both the referral and the accompanying telephone call by the referrer.
3. The timing of the MHA assessment to be explored with the referrer and any accompanying risk/system issues are to be made explicit so that the management of risk can be agreed/mitigated.

I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust’s top priority.

Report sections

Investigation and inquest

On 27 June 2019 I commenced an investigation into the death of Sharon Louise Kelly aged 44 years old. The investigation concluded at the end of the inquest on 12 November2019. The conclusion of the inquest was Sharon Louise Kelly killed herself. The contributing factors were as follows:-
• The timing of the Mental Health Act assessment was inadequate
• Failure to initiate the risk assessment upon arrival at the property by the EEAS
• Widespread insufficient communication between all services. including medical cause of death and short-form conclusion or narrative conclusion summarised]. The medical cause of death was 1a) hanging
11) alcohol and multiple drug overdose

Circumstances of the death

Ms Kelly had a long history of mental health and alcohol problems with frequent suicide attempts. She informed a family member that she would kill herself on the anniversary of her baby son’s death. The ambulance attended her property but did not enter, awaiting police attendance which was delayed. When, eventually the services entered the property Ms Kelly was deceased.

Inquest conclusion

-
• The timing of the Mental Health Act assessment was inadequate
• Failure to initiate the risk assessment upon arrival at the property by the EEAS
• Widespread insufficient communication between all services. including medical cause of death and short-form conclusion or narrative conclusion summarised]. The medical cause of death was 1a) hanging
11) alcohol and multiple drug overdose

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2020-0250
Date of report: 24 November 2020
Coroner: Caroline Beasley-Murray
Coroner area: Essex

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Jan 2021.

Sent to

EFAS

Essex Partnership University NHS Foundation Trust

Essex Police

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.