Source · Prevention of Future Deaths

Samantha Higgins

Ref: 2019-0483 Date: 13 Dec 2019 Coroner: Nadia Persaud Area: London (East) Responses identified: 1 / 1 View PDF

A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) in accessing crucial psychotherapy treatment.

Date 13 Dec 2019

56-day deadline 7 Feb 2020 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Sammi was cared for under the Access Assessment and Brief Intervention Team (AABIT) She was under the care of this team for almost three years_ Her care requirements went beyond "brief intervention" Whilst under the care of this team, Sammi had no overarching care plan_ No-one was appointed to oversee Sammi's care. evidence at the Inquest revealed that doctors working within the team were not aware of the possibility of service users under the AABIT having an overarching care plan or of service users having a key-worker assigned to them: Sammi suffered from emotionally unstable personality disorder and mood congruent psychotic symptoms_ She required psychotherapy treatment She was referred to the psychotherapy services in March 2017 . By the time of her death in February 2018, Sammi had not received psychotherapy: The Inquest heard that there could be delays of 17 months from referral to receipt of treatment It is considered that these ongoing lengthy delays give rise to a risk of future deaths_

Responses

1 respondent

North East London NHS Foundation Trust NHS / Health Body

29 Jan 2020 PDF

Action Planned

The Trust has considered the concerns and agreed to actions, outlined in an attached action plan, to improve care quality and patient safety. (AI summary)

View full response

Dear Ms Persaud, Re: Inquest touching upon the death of Samantha Louise Higgins Thank you for your letter dated 12 December 2019, when you issued Regulation 28 report regarding provision of psychotherapy services, care planning and key-working wthin Access Assessment and Brief Intervention Team We are extremely saddened by the death of Ms Higgins and are grateful for your report highlighting areas of concem identfied at the inquest hearing: We have considered the issues arosein the Regulation 28 report and agreed a number of actions to address these issues Please find enclosed the Trusts action plan to address these issues hope that the attached action plan adequately reflects Trust's commitment to improve care quality and patient safety and acts as reassurance to you that the Trust has taken this sad incident very seriously_ If you have any further queries, please contact my office on 0300 555 1201.

Report sections

Investigation and inquest

On the 22nd February 2018 commenced an investigation into the death of Samantha Louise Higgins _ The investigation concluded at the end of the Inquest on the 2oth November 2019, The conclusion of the Inquest was a narrative conclusion: Sammi Higgins suffered from emotionally unstable personality disorder; anxiety, depression and mood congruent psychosis: Her mental state had been deteriorating over the 10 months leading up to her death. Her presentation was characterized by overwhelming voices Sammi to harm herself. Sammi was under the mental health services throughout this period of time, but no overarching care plan was in place and she had no key-worker assigned to her. There was no assigned member of the mental health team with responsibility to ensure that Sammi's care plan was actioned. Sammi was deemed to be at moderate to high risk of suicide in early January 2018 was considered that her anti-psychotic medication needed to be changed as & priority: The change of medication was not communicated to the GP and no steps were taken to ensure that the medication change took place: On Friday the znd February 2018, Sammi presented to the mental health team after taking an overdose of medication and self-harming by cutting: She was deemed to be a low risk of suicide by the assessing nurses and discharged home with no mental health support offered over the weekend. On Saturday 34 February 2018 Sammi ingested a fatal combination of alcohol and tablets. Sammi took the action that lead to her death. Her intention at the time of this action is unknown due to the effect of the overwhelming voices upon her ability to form an intention.

Circumstances of the death

See above narrative conclusion.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

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Shared signals

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Report details

Reference: 2019-0483
Date of report: 13 December 2019
Coroner: Nadia Persaud
Coroner area: London (East)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Feb 2020 (estimated).

Sent to

North East London Hospital Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.