Source · Prevention of Future Deaths

Iain Macinnes

Ref: 2020-0118 Date: 24 Sep 2019 Coroner: Tom Osborne Area: Milton Keynes Responses identified: 0 / 1 View PDF

The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment Team, despite his expressed wish for their involvement in his care.

Date 24 Sep 2019

56-day deadline 18 Nov 2019

Responses identified 0 of 1

Community health care and emergency services related deaths Mental Health related deaths

Coroner's concerns

AI summary

The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment Team, despite his expressed wish for their involvement in his care.

View full coroner's concerns

The MATTERS OF CONCERNS are as follows: During the course of the evidence it became apparent that, despite the fact that the deceased had indicated that he wanted information to be shared with his family and for them to be involved in his care, they were not informed that his condition had deteriorated and that he had been transferred to the Home Treatment Team although it was widely accepted that it is important that the family are involved in a patients treatment and care. The process for recording details of the family and for keeping them informed needs to be reviewed by the trust and proposals for reform considered.

Report sections

Investigation and inquest

On 23/01/2019 I commenced an investigation into the death of Iain Neil MACINNES aged 65. The investigation concluded at the end of the inquest on 31st July 2019. The conclusion of the inquest was: Narrative conclusion: The deceased's mental health began to deteriorate throughout December 2018 and his care was transferred to the Acute Home Treatment Team although this was not communicated to his family. There was a failure to recognise the extent of his deterioration that resulted in lost opportunities to admit him to hospital for further treatment and he was found hanging at Milton Keynes on 17th January 2019.

Circumstances of the death

The deceased was found hanging in his home at Milton Keynes on the 17th January 2019

Action should be taken

7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18th November 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
- The family of Mr Macinnes I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Tom OSBORNE Senior Coroner for Milton Keynes Dated: 24 September 2019

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Report details

Reference: 2020-0118
Date of report: 24 September 2019
Coroner: Tom Osborne
Coroner area: Milton Keynes

Responses identified

Responses identified 0 of 1

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Nov 2019.

Sent to

Central Northwest London NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.