Reece Lapina-Amarelle

Coroner's concerns

AI summary

The report identifies a lack of resources and treatment for individuals with serious mental illness and substance misuse issues, as well as insufficient information sharing between mental health services and substance misuse services.

View full coroner's concerns

In my opinion there is a risk that future similar deaths will occur unless action is taken: (1) There are no resources and no system of treatment for people who present with serious mental illness and alcohol or drug misuse histories They They

(2) There is insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service).

(3) That latter service is voluntary and, outside the criminal justice system, the subject cannot be forced to access and receive help or to cooperate with that service (4) In my opinion the Mental Health Act is out of date in that it does not recognise or accept responsibility for providing a plan of action to deal with people such as Reece_ (5) Twenty years ago the connection between the use of strong drugs in teenage years and subsequent mental health (often very serious) was not fully recognised: However nowadays there is far greater use of drugs which are growing ever stronger; and a very considerable number of people with mental health issues in prison or in the community have developed or worsened their conditions by the use of cannabis and other illegal substances. The Mental Health Act still concentrates on therapy without giving sufficient emphasis, in my view, to safety and, in blunt terms, keeping people alive In my view without action these issues are simply going to get worse

Responses

2 respondents

NHS England NHS / Health Body

PDF

Noted

NHS England expresses condolences and acknowledges the concerns raised, referencing existing initiatives to improve mental health services and digital tools. It notes that the Department of Health and Social Care is developing a response to the Independent Review of the Mental Health Act, and that the government has committed to publishing a White Paper. (AI summary)

View full response

Dear Mr Romilly Craze, Re: Regulation 28 Report to Prevent Future Deaths Mr Reece Tristan Lapina-Amarelle, deceased 25.06.2018 Thank you for your Regulation 28 Report (hereinafter the 'report') dated gh August 2019 concerning the death of Mr Reece Lapina-Amarelle on 25"h June 2018. Firstly, would like to express my deep condolences to Mr Amarelle's family. Your report confirms that;, following the inquest which concluded earlier this year, Mr Lapina- Amarelle died by suicide as result of multiple injuries. An incident occurred at Beachy Head on the same day Mr Lapina-Amarelle was discharged from Bodiam Ward, which is part of Sussex Partnership NHS Foundation Trust; Alongside your report you have shared witness statement and the Serious Incident Review report, and you have raised concerns in your report to both the Secretary of State for Health and NHS England regarding the following:
1) The unavailability of resources and a system of treatment for people with serious mental illness and alcohol or drug misuse histories;
2) The insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service);
3) The fact that CGL (the Substance and Alcohol Misuse Service) is voluntary and that; outside criminal justice system, the subject cannot be forced to access and receive help from that service;
4) The fact that; in your opinion, the Mental Health Act is out of date and does not recognise or accept responsibility for providing plan of action to deal with people such as Mr Reece;
5) The fact that; in your opinion, the Mental Health Act still concentrates on therapy without giving enough emphasis to safety and preventative measures, particularly in a context of history of substance misuse NHS England and NHS Improvement key the

note that a copy of your report has been sent to the Trust for a response on the specific circumstances relating to Mr Lapina-Amarelle's death, which acknowledge is a particularly tragic and difficult case. However; wanted to highlight some national policies and priorities which believe are relevant to the concerns you have raised in your report as both having bearing on Mr Lapina-Amarelle's death and ongoing concerns for patient safety_ Concern The unavailability of resources and a system of treatment for people with serious mental illness and alcohol or drug misuse histories: Concern 3 The fact that CGL (the Substance and Alcohol Misuse Service) is voluntary and that; outside the criminal justice system, the subject cannot be forced to access and receive help from that service: The Health and Social Care Act 2012 transferred statutory responsibility for commissioning of public health services, including drug and alcohol services, to local authorities. NHS England and NHS Improvement do recognise it is a very important issue, with significant implications for the mental health of individuals, particularly for those affected by coexisting severe mental illnesses (SMI) and substance misuse , like Mr Lapina-Amarelle. We also recognise the importance of ensuring closer working between mental health services and substance misuse services to ensure people's needs are met in an integrated, holistic and timely manner. As such, the ongoing move towards Integrated Care Systems (ICSs) across England is intended to help address some of these issues and to provide joined up health and care to whole populations across the NHS, social care and public health In recognition of the above, we are taking specific steps to improve access to, and quality of, support for people with co-existing SMI and substance misuse. The NHS Long Term Plan, published earlier this year, details how new and integrated models of primary and community health services will transform the delivery of mental health care for adults and older adults with SMI; including people with a 'personality disorder' and those with co-existing substance misuse As the NHS Mental Health Implementation Plan 2019/20 2023/24 sets out; this new community-based offer; backed by significant investment over the next five years, will include access to psychological therapies, improved physical health care , employment support;, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use The Implementation Plan is available here: https Ilwlongtermplan nhs Uklwp-contentluploads/201.9/07Inhs-mental-health: implementation-plan-2019-20-2023-24pdf: By 2023/24, the new models of care, underpinned by improved information sharing, will give at least 370,000 adults and older adults per year greater choice and control over their care, and support them to live well in their communities including dedicated provision for groups with specific needs, such as adults with a 'personality disorder' diagnosis To support improvements in the commissioning and provision of services for people with CO- existing SMI and substance misuse , National Institute for Health and Care Excellence (NICE) published a national guideline (NG58) in November 2016,which is available online here: https Iwnice org uklguidancelng58: NICE is also expected to publish new quality standard on this topic soon to provide further detail to clinical teams as to how can best meet the needs of this group of people. Its draft standard is available online here: https Ilwnice org_uklquidancelgid-9s10078/documentsldraft-quality-standard: Public Health NHS England and NHS Improvement key the the they

England, as the lead organisation responsible for supporting local government with its public health responsibilities, has also published guidance for commissioners and service providers on co-occurring mental health and alcoholldrug use conditions, which is available online here: https Ilassets publishing service gov uklgovernmentluploadslsystemluploadslattachment_datalf ile/625809/Co-occurring mental health and_alcohoL_drug_ use_conditions_pdf Concern 2 The insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service); The NHS Long Term Plan is committed to ensuring that by 2024 secondary care providers in England, including acute , community and mental health care settings, will be fully digitised, including clinical and operational processes across all settings, locations and departments_ Data will be captured, stored transmitted electronically, supported by robust IT infrastructure and cyber security, and Local Health and Care Records will cover the whole country. As part of this, a number of steps are taken, led by NHS England and NHS Improvement; and NHSX, to enable the safe and secure sharing of digital records The Local Integrated Health and Care Records programme will provide strategic vision for safely and securely sharing data across different NHS and partner organisations (including substance misuse services). The aim of the programme is to create an information sharing environment that helps our health and care services to continually improve the care that we deliver. This includes: ensuring that health and care professionals have access to comprehensive care record with the information they need to inform their care decisions, when and where they need it; empowering people to look after themselves better and make informed choices about their own health and care; and being able to analyse the data to enable more precise and actionable interventions and support the development of population health management NHS England is also working with the mental health trust Global Digital Exemplar programmes to develop a range of basic and more advanced tools to support decisions on care across the pathway; this includes the identification of need, detection of risk and the application of best practice. In parallel to this, NHS England and NHS Improvement and NHSX are working to improve the availability of mental health information and evidence-based resources online. This includes local crisis service directories. Concern 4 _ The fact that; in your opinion, the Mental Health Act is out of date and does not recognise or accept responsibility for providing plan of action to deal with people such as Mr Reece; Concern 5 The fact that; in your opinion, the Mental Health Act still concentrates on therapy without giving enough emphasis to safety and preventative measures, particularly in a context of a history of substance misuse: The Independent Review of the Mental Health Act (MHA) 1983 has set out recommendations for the Government on how the MHA and associated practice needs to change. Its report can be accessed online here: https ILW9Ov Uklgovernmentlpublicationslmodernising-the-mental NHS England and NHS Improvement and being

health-act-final-report-from-the-independent-review As the government department responsible for this legislation; the Department of Health and Social Care is currently developing a response to the Independent Reviews recommendations, and NHS England and NHS Improvement are involved in, and supporting this process_ The Government has committed to publishing a White Paper before the end of the year: 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 and Social Care Central Government

PDF

Action Planned

The Department of Health and Social Care acknowledges the concerns and notes the NHS England and Improvement response. They commissioned a review of the Mental Health Act and will publish a White Paper setting out the Government's response. (AI summary)

View full response

Nadine Dories MP Parliamentary Under Secretary of State for Mental Health; Department Suicide Prevention and Patient Safety of Health & Social Care 39 Victoria Street London SW1H OEU 020 7210 4850 Your Ref: ARCILEH/Lapina-Amarelle/01252-2018 Our Ref: PFD-1186842 Mr Alan Craze HM Senior Coroner; East Sussex HM Coroner's Office 31 Station Road Bexhill-On-Sea TN40 IRG S+lNovember 2019 1V Aln, Thank you for your correspondence of 12 August to Matt Hancock about the death of Mr Reece Lapina-Amarelle. Lam responding as Minister with responsibility for mental health and [ am grateful for the additional time in which to do s0. Firstly, I would like to say how very sorry was to read of the tragic circumstances of Reece' s death: I can appreciate how devastating his loss, at such a young age and in such circumstances, must be for his family and loved ones and offer my most heartfelt condolences to them Inote that the Sussex Partnership NHS Foundation Trust conducted a Serious Incident Review into Reece'$ death that made important recommendations for action, including steps to improve communication with families and carers. [welcome the action taken by the Trust However; it is vital that the Trust does consider carefully learnings that can be taken from Reece'$ tragic death to reduce the chance of such a situation from ever happening In view of the serious nature of this case, I have asked my officials to make your report and the circumstances of this case known to the Care Quality Commission, the independent regulator of healthcare services in England. Iwill now turn to specific matters of concern in your report about the Mental Health Act and treatment for people with co-occurring substance misuse and mental health conditions In preparing this response, my officials have made enquiries with NHS England and NHS Improvement to whom you also issued your report. [will not repeat the detail of their response. However; [ note that it explains the work that is From again.

taking place to strengthen the provision of integrated care across the NHS, social care and public health, and transform the support for those with severe mental illness and co-occurring substance misuse through the actions outlined in the NHS Mental Health Implementation Plan 2019/20 2023/24' The response also sets out the commitment to improve information sharing in the NHS through digitisation and programmes such as Local Integrated Health and Care Records? , which aims to enable the safe and secure sharing of inforation to support improvements in care misuse is common among people with mental health problems and we understand that people with co-occurring substance misuse and mental health conditions can find it difficult to access the care need. We recognise that we need to do more to tackle this issue and ensure that those affected receive treatment that meets their needs in relation to both mental health and drug dependency: We are clear that commissioners and providers of services have a joint responsibility to work collaboratively to meet the needs of people with cO-occurring conditions Public Health England has developed guidance' to support commissioning and provision ofjoined up services for people with a dual diagnosis of mental health and substance misuse problems The guidance sets out tangible principles for services should work; including that each person should have access to a care cO-ordinator to help ensure all their needs are addressed: In addition; the National Institute for Health and Care Excellence (NICE) has published a guideline on `Coexisting severe mental illness and substance misuse' that aims to support improvements in the provision of cO-ordinated services A Quality Standards , published in August 2019, provides further guidance to healthcare professionals on the assessment, management and care of those with cO-occurring severe mental illness and substance misuse. The Government continues to support the 'no wrong door' approach when people present to services with cO-occurring conditions Commissioning guidance encourages services to respond collaboratively, effectively and flexibly, offering btpst WWW Jongtenplan nhs uklwp-contentuploads 2019 07 nhs-mental-health-implementation-plan-2019-20- 2023-24pdf Wtps" WWW englandnhs uklpublication/local-healb-and-care-record-exemplars/ https: assets L publishing service Lov uklgovemmenuuploads/systemV/uploads/attachment_datalfile 625809 Co- occuing_mental_health_and_alcohol use_conditions pdf https: Www nice_Org uklguidance ng58 hupsr Wwwnice Og uklguidance gs188 Drug - they - how drug

compassionate and non-judgemental care centred around the persons needs which is accessible from every access point: Turning to treatment; under the Mental Health Act, dependence on alcohol or drugs is not considered to be a disorder or disability of the mind: The Act's Code of Practice6 does; however; allow for and alcohol treatment to be given "if that is an appropriate part of treating the mental disorder which is the primary focus of the treatment" (Mental Health Act Code of Practice, paragraph 2.13) and it also allows for disorders caused by alcohol and substance misuse to be considered as mental disorders for the purposes of the Act The Act allows for the detention and treatment of people with a mental disorder when there is a concern for a person's health and safety or that of other people and, where a patient is at risk of suicide; there is an expectation that the Act is used to protect the patient: AS practitioner may prefer to try to keep the patient in hospital informally or use the Mental Capacity Act'$ Deprivation of Liberty Safeguards to detain the patient: The Act does not; however, set out recommendations for therapy or other treatments; as these are matters for healthcare professionals. More generally, as you are aware, we commissioned a full and independent review of the Mental Health Act: The Independent Review of the Mental Health Act was published on 6 December 20187. The Review made 154 recommendations. If implemented would give more legal weight to people's choices, make the use of compulsion more targeted and transparent, and modernise services to provide patient- centred care which respects the patient'$ dignity. We will publish a White Paper which will set out the Government'$ response, in full, to the Independent Review of the Mental Health Act; and pave the way for new legislation: [ hope this response is helpful. Thank you for bringing these concerns to my attention. Nzc NADINE DORRIES https: WWWE gov uklgovemmenupublications code-ofpractice-mental-health-act-L983 hutpsi WWW gov uklgovemmentpublications modemising-the-mental-health-act-final-report-from-the-independent- review drug they

Report sections

Investigation and inquest

On 29"h June 2018 commenced an investigation into the death of Reece Tristan Lapina-Amarelle, aged 20 years. The investigation concluded at the end of the inquest on 25"h April 2019_ am attaching a copy of the Record of Inquest; The conclusion of the inquest was suicide and the medical cause of death was multiple injuries

Circumstances of the death

Two documents were presented to me which are a powerful statement of the peculiar problems the authorities faced in Mr Lapina-Amarelle's situation_ can do no better than to attach copies of those documents are the statement of Doctor the psychiatrist responsible for him when he was admitted (on very many occasions) , coupled with the Level 2 Comprehensive Serious Incident Review Report A study of those two documents will give the history and it can be seen that all available in-patient and community programmes had been unsuccessful, and the Sussex Partnership Foundation Trust (the Mental Health Services) simply had no other option but to detain him in hospital or to discharge him: He had been providing drugs to other in-patients in hospital and so understandably they did not want him to continue there_ therefore discharged him with the full knowledge that he would immediately proceed to try to take his life, which is exactly what he did. The only preventative measure that the Trust could take was to telephone the Beachy Head Chaplains and the Police to warn them that Reece was on his way to Beachy Head.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action,

Similar PFD reports

Shared signals

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Source links