Source · Prevention of Future Deaths

Stephen Kennedy

Ref: 2019-0039 Date: 7 Feb 2019 Coroner: Louise Hunt Area: Birmingham and Solihull Responses identified: 3 / 3 View PDF

A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health beds led to further self-harm and suicide attempts.

Date 7 Feb 2019

56-day deadline 5 Apr 2019

Responses identified 3 of 3

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

1. The deceased suffered from emotional unstable personality disorder and was in crisis for most of 2018. The recommended treatment for his condition was psychological therapy. He had not had any psychological input since 2010. The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services. He had to be under the community mental health team to be able to access psychological services. There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services. Throughout 2018 he never received any psychological services. I am concerned that the main treatment option for the deceased was not available to him due to internal structures and long waiting lists.
2. In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern.

Responses

3 respondents

Department of Health and Social Care Central Government

8 Feb 2019 PDF

Action Planned

The Department of Health and Social Care highlights national initiatives to improve mental health services, including expanding CRHTTs, integrating primary and secondary care, and establishing a national single point of contact for mental health crises. They also reaffirm commitment to suicide prevention and will continue measures through the existing suicide reduction programme. (AI summary)

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From Jackie Doyle-Price MP Parliamentary Under Secretary of Stale for Menlal Health Department Inequalities and Suicide Prevention of Health & Social Care 39 Victoria Street London SW1H OEU 020 7210 4850 Your Ref: 126699- Stephen Anthony Kennedy Our Ref: PFD-1166496 Ms Louise Hunt HM Senior Coroner; Birmingham & Solihull Coroner's Court 50 Newton Street Birmingham B4 6NE S1, April 2019 Drx A 4tut Thank you for your correspondence of 8 February 2019 to the Secretary of State about the death of Mr Stephen Anthony Kennedy. Iam replying as Minister with portfolio responsibility for mental health services. Firstly, I would like to say how sorry I was to read of the circumstances of Mr Kennedy's death: [ appreciate his loss must be extremely distressing for his family and loved ones and I offer my sincerest condolences It is essential that we look to make improvements where we can to ensure the safety of healthcare and prevent future deaths and [ am grateful to you for bringing these matters to my attention: Your report raises matters of concern around access to psychological therapies and the availability of inpatient beds for those requiring mental health treatment: You will know that the provision of mental health services is a matter for the NHS locally, except where specialised services are required and NHS England is the responsible commissioner: You have issued your report to the Birmingham and Solihull Mental Health NHS Foundation Trust and the Birmingham and Solihull Clinical Commissioning Group (CCG), and I expect the local NHS to take firm action to respond to the concerns and leam from Stephen's death to ensure the safety of healthcare services: I would like to explain the action we are at a national level to improve access to treatment for those with severe mental illness. taking

On the availability of beds in the acute mental health sector; we are aware that the number of mental health beds overall have reduced and this is in part due to the growth of care in the community It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3,2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent However; it remains the responsibility of local commissioners to determine the levels of service provision based on the needs of their local populations, and I note that the NHS in Birmingham and Solihull has taken action to commission a further 32 inpatient beds. To support the NHS, we have committed to a comprehensive expansion of mental health services and are backing this up with an additional E2.3billion investment in real terms by 2023-24. This commitment is made clear in the NHS Long Term Plan' , published in January 2019 by NHS England. With regard to access to psychological therapies, on a national level, I would like to assure you that we recognise the importance ofboth psychological interventions and, where clinically appropriate, access to National Institute for Health and Clinical Excellence (NICE) concordant psychological therapy for people receiving secondary mental health care in both inpatient and community settings A matter of concern in your Report is that patients cannot access psychological therapy while under the care of the Home Treatment Team (HTT) By 2020/21, Crisis Resolution and Home Treatment Teams (CRHTTs) should provide a 24 seven day community-based mental health crisis response and offer intensive home treatment as an alterative t0 acute inpatient admission. CRHTTs should aim to deliver care in line with quality benchmarks described in the University College London CORE fidelity criteria? , a quality improvement tool. Significantly, this criteria includes the provision of brief psychological intervention an initial urgent and emergency mental health response and, where required, ongoing therapeutic psychologically-informed care delivered by a multi-disciplinary home treatment team, benefitted by input from clinical psychologists. Over E40Omillion of supporting investment is made available over four years from April 2017 for the expansion of CRHTTs, in line with CORE criteria. https: WWK longterplan nhs ukl httpsz www uclac uklcore-resource_packlfidelity-scale large hour, during being

Overall, the NHS long-term plan sets out a programme of expansion and improvement for mental health services to deliver parity of esteem between mental and physical illness. Italso sets out proposals on building increased integration between primary and secondary care so that that those experiencing mental ill-health; including those with complex mental health needs or a diagnosis of personality disorder;, can access the right support. A new community-based offer for people with Severe Mental Illness 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. This will give 370,000 adults and older adults greater choice and control over their care, and support them to live well in their communities. Crisis care is also a element of the Long Term Plan and this includes establishing national, single point of contact, for anyone experiencing mental health crisis through the NHS] 1 1 service. This means that people in crisis will be able to access a trained mental health professional when need to. Finally, the long-term plan reaffirms the NHS's commitment to make suicide prevention priority over the next decade; and sets out further measures for suicide prevention, including full coverage across the country of the existing suicide reduction programme. I hope this information is helpful in setting out our commitment to improve access to mental health services and the measures taken to support the NHS to deliver high quality, effective services for those experiencing mental ill-health. CC JACKIE DOYLE-PRICE key - they being

Birmingham and Solihull Mental Health NHS Trust NHS / Health Body

5 Apr 2019 PDF

Action Planned

The Trust is developing training and guidance for staff on Personality Disorder and patients with Personality Disorder, to be mandated for all staff working within our Home Treatment Teams during 2019/20. A Personality Disorders Strategy which includes clinical standards to be met for patients with a diagnosis of Personality Disorder is being led by the Trust's Chief Psychologist. (AI summary)

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Dear Mrs Hunt

REGULATION 28 REPORT – MR S KENNEDY Thank you for your communication relating to the investigation into the death of Stephen Anthony Kennedy. I note that the investigation concluded at the end of an inquest on 7th February 2019 with a conclusion of Suicide. It is evident that the deceased suffered from emotional unstable personality disorder and depression. At the time of his death Stephen had been under the care of our mental health team for several years. His condition resulted in frequent attempts to self harm which was managed through hospital admissions and at home with support from the home treatment team. His condition deteriorated during 2018. He was seen regularly by the mental health team with his last admission being from 22/08/18 until 11/09/18. He was then reviewed by the home treatment team. Stephen presented to Good Hope Hospital on 07/10/18 with chest pains and low mood. He was assessed by a mental health nurse and arrangements were made for ongoing support from the home treatment team and to see his consultant on 08/10/18. Tragically, Stephen was found hanging from a door frame at his home address on 08/10/18 and was declared deceased at 10.07. Our serious incident investigation RCA report highlighted a gap in care relating to non compliance with NICE guidelines for psychological therapy whereby Stephen had not been in receipt of Psychological Therapy throughout his time on our Community caseload. During the course of the inquest the evidence revealed matters giving rise to concern. The matters of concern are noted as follows:-
1. The deceased suffered from emotional unstable personality disorder and was in crisis for most of 2018. The recommended treatment for his condition was psychological therapy. He had not had any psychological input since 2010. The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services. He had to be under the community mental health team to be able to access

2 psychological services. There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services. Throughout 2018 he never received any psychological services. I am concerned that the main treatment option for the deceased was not available to him due to internal structures and long waiting lists.
2. In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern. With regard to the matter of Psychological Therapy, I am able to confirm that we now have a plan for investing in clinical psychology capacity within our Home Treatment Team services. From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team. Approval has been given to advertise these posts and this will help us to ensure compliance with NICE guidance and to deliver clinically effective care as per recommended guidelines. The Clinical Psychologist will also contribute to multi disciplinary team assessments, discussions and decisions relating to care planning and treatment options for patients, aswell as providing supervision to other members of the team. We are also increasing nursing capacity to ensure that community caseloads are more manageable. In addition, we have developed a tiered training programme in the best practice management of patients with Personality Disorder. This will be a mandated training requirement for all staff working within our Home Treatment Teams during 2019/20. Our Chief Psychologist is leading a Personality Disorders Strategy which includes clinical standards to be met for patients with a diagnosis of Personality Disorder. We are currently in discussion with our Clinical Director of Community Mental Health Teams about the opportunities to roll out these standards in a clinically effective way. There are some challenges relating to resources which we have raised with our Commissioners and at the time of writing this response these have not yet been resolved. We will continue to pursue this matter and also seek to understand any further opportunities for improvement if investment is not forthcoming. On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-  A review of patient flow  Efforts to reduce delayed discharges  Appointment of patient flow coordinators In the longer term, our Estates Strategy aims to increase the inpatient bed stock of the Trust to try to meet the increased demands and acuity of patients across the City and in Solihull.

3 I would like to take this opportunity to express my sincere apologies for the failings in the care delivered to Stephen by our Trust and to extend these apologies to his family members. This is clearly a tragic event for all and one that the Trust is taking seriously in its efforts to prevent future incidents of this nature. I do hope that this response gives you some assurance of the efforts being taken by the Trust in response to your matters of concern.

NHS Birmingham and Solihull ICB Integrated Care Board

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Noted

The CCG acknowledges the coroner's concerns and is unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function and to also improve processes for learning from deaths at the earliest opportunity. (AI summary)

View full response

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NHS Birmingham and Solihull CCG: Response to the Birmingham and Solihull Coroner’s Regulation 28 report to prevent future deaths
1. Introduction

1.1 This report provides a response to the HM Coroner, in respect of the Regulation 28 report issued to NHS Birmingham and Solihull Clinical Commissioning Group (the CCG) relating to the death of Stephen Anthony Kennedy.

1.2 Two issues have been raised in the Regulation 28 report, to which the CCG is required to respond:
• A delay in August 2018 in obtaining an inpatient bed
• The long waiting time in 2018 for accessing psychological therapy.
1.3 The CCG has recently provided a comprehensive report to the HM Senior Coroner for Birmingham and Solihull on mental health services in the area, in response to a Regulation 28 report to prevent future deaths. Much of the information contained in that report is pertinent to the circumstances of this particular case and, therefore, we will not seek to repeat those details in this response.
2. Background and context

2.1 On 8th February 2019, the CCG received a Regulation 28 Report to Prevent Future Deaths from the Birmingham and Solihull Coroner, relating to the death and subsequent inquest, of Stephen Anthony Kennedy who sadly passed away on 8th October 2018.

2.2 Stephen had been known to mental health services in the area for many years and in 2018 had been both an inpatient and under the Home Treatment Team. His care was provided by Birmingham and Solihull Mental Health Foundation Trust (BSMHFT).

2.3 Statements submitted to the inquest confirm that on 13th August 2018 Stephen was identified as needing admission to an informal inpatient bed. However, one was not immediately available and on 19th August Stephen was admitted to the Psychiatric Decision Unit (PDU), and transferred to the Zinnia Centre on 22nd August 2018 before being discharged on 11th September 2018. The CCG has no direct knowledge of these events.

2.4 Stephen was identified as needing psychological therapy in early May 2018. The referral was escalated on 25th May but there is no evidence available to the

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CCG that identifies whether this service was ever accessed, nor what steps were taken to chase the referral. It is understood that Stephen accessed psychological therapies whilst an inpatient in the Zinnia Centre.

2.5 The CCG commissions services from BSMHFT through an NHS standard contract. The standard contract sets out the required operational standards, as well as national and local quality requirements. Contracts and provider performance are monitored by the CCG through a range of reports and meetings which include:

2.5.1 Monthly contract review meetings, which include oversight of performance, activity and quality.

2.5.2 A range of contractual key performance indicators and monthly and/or quarterly reports, which include data relating to patient experience, patient safety and clinical effectiveness.

2.5.3 In accordance with the NHS England Serious Incident Reporting Framework (2015), the reporting of serious incidents to the CCG within two days of the provider becoming aware that a serious incident has occurred.

2.5.4 Quarterly reporting from providers regarding their systems and processes for learning from deaths, as set out in the National Quality Board Publication: National Guidance on Learning from Deaths (2017).

2.6 The CCG has quality monitoring processes which include serious incident reporting and reacting systems, clear reporting and monitoring requirements. All investigations into serious incidents are quality checked by the CCG to ensure that necessary actions are identified and implemented.

3. Understanding and responding to capacity and demand
3.1 Since 2016, the CCG (both in the current form and as three former CCGs, prior to the Birmingham and Solihull CCG merger on 1st April 2018) has taken a number of steps, with partner organisations, to understand and respond to concerns about capacity and demand within the local mental health system.
3.2 The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment. Part of this approach involves the CCG being an active partner in the Birmingham and Solihull Sustainability and Transformation Partnership (the STP), and the Mental Health Programme

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Delivery Board. The ambition of the STP is to achieve sustainability, through a strong focus on prevention and recovery.
3.3 The CCG has a Mental Health Programme Delivery Board with a plan of action which includes a range of initiatives to deliver measurable changes for mental health services. This includes reducing the number of patients being placed in inpatient units that are out of the local area to zero by 2021. The plan is jointly owned by the CCG, Birmingham Women’s and Children’s NHS Foundation Trust, BSMHFT, Solihull Metropolitan Borough Council and Birmingham City Council. A ‘zero suicide’ ambition has been committed to, which is led by the local authorities’ respective public health teams. This ambition will be supported by evidence based, preventative action and high-quality crisis support, as well as reducing stigma around mental health and improving access through early intervention services.
3.4 Psychological therapy services for people under the care of BSMHFT forms part of the provider’s internal pathway and as such waiting times are not monitored by the CCG. The CCG’s approach is to increasingly commission for outcomes rather than inputs. In line with this, commissioners have set out their intention that community-based mental health services should operate distinct treatment pathways for people with psychotic disorders and those with mood and personality disorders. Pathways will be focused on the delivery of treatment and support that promotes recovery alongside the proportionate management of risk. Providers will be expected to put in place a workforce model that reflects this approach and affords access to treatment options including psychological therapies. This change will be formalised through a Service Development and Improvement Plan (SDIP) which will form a part of the contract between the CCG and BSMHFT for 2019/20.
3.5 The CCG has recognised and reacted to the increased demand for mental health services. To date, this has included:
3.5.1 An independent system simulation modelling exercise, which was jointly commissioned with Forward Thinking Birmingham (FTB), the provider of mental health services for those aged up to 25 years, and BSMHFT, to develop an informed response on the best solutions to address demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016. A key recommendation of the exercise was to agree a strategy for the support and treatment of people with a diagnosis of personality disorder. This strategy is now being mobilised by BSMHFT and FTB. An SDIP has been developed for 2019/20 which formalises the implementation of the strategy and the CCG has provided additional funding for the appointment of a Clinical Lead for Personality Disorder within BSMHFT who will lead this work.

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3.5.2 An independent review of patients’ journeys into and out of inpatient mental health beds was commissioned by the STP. The review considered whether alternatives to admission could have been used and whether patients stayed in hospital longer than necessary. The review found that in both cases, improvements could be made to help avoid unnecessary admissions and reduce the time taken to discharge patients.

3.5.3 Supporting operational initiatives to reduce delayed transfers of care, where CCG funding of individual packages of care under Section 117 (jointly funded packages of health and social care) are required to facilitate discharge from hospital.

3.5.4 Weekly, and daily peak period, delayed discharge escalation calls with providers and local authority social work teams, in order to escalate any delays and for swift resolution.

3.5.5 Whilst the CCG is committed to reducing the use of admissions to inpatient care outside the local area, commissioners continue to support the use of admissions to other NHS mental health trusts within the MERIT Vanguard1 and to independent hospitals, where no locally commissioned beds are available, and an admission is deemed necessary. BSMHFT are able to make such admissions without prior approval from the CCG.

3.5.6 Working closely with BSMHFT and FTB as part of an NHS England collaborative to seek further ways to reduce the need to admit patients out of the local area. This work includes taking learning from other areas that have enjoyed success in achieving change. Commissioners are in discussion with BSMHFT to agree ways in which resource can be shifted internally to support this work.

3.5.7 Using evidence and data analysis to inform investment and approach.

3.5.8 Recognising that capacity is impacted by a wide range of factors and encouraging action at all levels across the mental health care pathway.

3.5.9 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase).

3.5.10 In 2018/19 providing additional investment in BSMHFT amounting to a £3,117,000 (2.4% increase).

1 The MERIT Vanguard was supported through the Department of Health New Models of Care Programme. It is a partnership between four NHS mental health providers in the Midlands (Birmingham and Solihull Mental Health NHS Foundation Trust, Black Country Partnership NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust and Coventry and Warwickshire Partnership NHS Trust. The Vanguard has sought to improve crisis care through a more flexible use of bed stock across the region and by seeking to embed ‘recovery principles’ in practice.

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3.5.11 This further investment reflects growth of 3.03% in core mental health budgets, in accordance with the CCG’s investment standard, which is above the national growth standard of 2.85%.

3.6 It is acknowledged, through contract review meetings, there have been discussions with BSMHFT about funding and capacity, as capacity and demand issues are discussed through the contract review mechanism. Contract negotiations for services provided in 2019/20 have focused on measures to improve capacity through investment and service development and improvement.

4 Conclusion
4.1 The CCG aspires to there being no avoidable deaths in Birmingham and Solihull and takes every reported unexplained death very seriously. The CCG is continuously working with providers to improve the quality and safety of services, as well as looking at new and innovative ways to improve all mental health services.

4.2 In response to concerns previously raised by HM Coroner, the CCG has undertaken a review of the processes for managing serious incidents, but also whether a shortage of funding may have contributed to these untimely deaths. The CCG has been unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function and to also improve processes for learning from deaths at the earliest opportunity.

4.3 The CCG recognises the need to take a multiagency approach to the prevention of deaths, including creating robust partnerships with mental health support services e.g. substance abuse services, community intervention and crisis management. The CCG must also ensure that inpatient beds are maximised and available for those who need them.

4.4 The CCG will continue to keep under review the pressures on mental health services and the need to develop new initiatives to manage patient flow and improve services.

4.5 The CCG recognises that there has been increased demand for mental health services since 2016, and has responded to this additional pressure with increased funding and through working with FTB, BSMHFT and the STP to look at different ways of working throughout the system. The CCG will monitor the situation to ensure that all partnership working across Birmingham and Solihull is focussed on improving access and the quality of care.

Report sections

Investigation and inquest

On 12/10/2018 I commenced an investigation into the death of Stephen Anthony Kennedy. The investigation concluded at the end of an inquest on 7th February 2019. The conclusion of the inquest was Suicide.

Circumstances of the death

The deceased suffered from emotional unstable personality disorder and depression. He had been under the care of the mental health team for several years. His condition resulted in frequent attempts to self harm which was managed through hospital admissions and at home with support from the home treatment team. His condition deteriorated during 2018. He was seen regularly by the mental health team with his last admission being from 22/08/18 until 11/09/18. He was then reviewed by the home treatment team. He presented to Good Hope Hospital on 07/10/18 with chest pains and low mood. He was assessed by a mental health nurse and arrangements were made for ongoing support from the home treatment team and to see his consultant on 08/10/18. He was found hanging from a door frame at his home address on 08/10/18 and was declared deceased at 10.07. During 2018 he did not receive any psychological therapy as recommended by NICE.

Following a post mortem the medical cause of death was determined to be:

1a. HANGING

Copies sent to

NHS England and CQC

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2019-0039
Date of report: 7 February 2019
Coroner: Louise Hunt
Coroner area: Birmingham and Solihull

Responses identified

Responses identified 3 of 3

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Apr 2019.

Sent to

Birmingham and Solihull Mental Health NHS Trust

Birmingham Cross City Clinical Commissioning Group

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.