Source · Prevention of Future Deaths

Daniel Young

Ref: 2018-0240 Date: 26 Jul 2018 Coroner: Shirley Radcliffe Area: London (Inner) West Responses identified: 1 / 1 View PDF

GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.

Date 26 Jul 2018

56-day deadline 18 Nov 2018 est.

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.

View full coroner's concerns

_ When ML was discharged to the care of his GP by the Community Mental Health team, he was warned not to stop his medication because of the risk of relapse. GP surgeries do not routinely monitor that psychiatric patients are collecting their antipsychotics. Evidence revealed that it is not uncommon for such patients their medication and relapse. Relapse puts them at risk of harm to themselves and, sometimes, they pose a risk to others Following the death of Mr Young, the GP responsible for the care of ML has implemented a system within the practice to monitor the collection of antipsychotic medication of their patients. This is funded by the practice. attach a copy of the Protocol for Monitoring Collection of Antipsychotic Prescriptions:

Responses

1 respondent

Department of Health Social Care Central Government

2 Sep 2018 PDF

Action Planned

NHS England is developing a framework for community mental health services to improve joint working between primary and secondary services. They will also write to GP practices about monitoring antipsychotic medication prescriptions and explore alerts within primary care clinical systems. (AI summary)

View full response

From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health and Inequalities Department of Health & Department of Health and Social Care 39 Victoria Street Social Care London SW1H OEU Our reference: PFD 1143538 Dr Shirley Radcliffe HM Assistant Coroner; Inner West London Westminster Coroner' s Court 65 Horseferry Road London SWIP 2ED J2 September 2018 Oecv Dr Thank you for your letter of 26 July to the Secretary of State for Health and Social Care about the death of Mr Daniel Young: I am responding as Minister with portfolio responsibility for Mental Health: Ihave noted carefully the concerns in your report: My officials have made enquiries with NHS England on these matters. You will be interested to know that NHS England is currently developing a framework for community mental health services which will articulate models of improved joint working between primary and secondary mental health services in community settings. This will support teams to work together to plan a patients care holistically and ensure that any transitions between settings and different teams can be facilitated with the relevant professionals having ready access to all relevant information. This is particularly important for people transitioning between service settings, for whom medication reviews need to be followed up. In addition; I am advised that the framework will set out quality benchmarks and recommendations for local systems, reflecting current evidence and existing guidance Raddple

published by the National Institute for Health and Care Excellence (NICE), to support commissioners and providers across the health and care system to model and implement the framework: It will include considerations regarding medication adherence and medicines optimisation: To support improved care coordination in the community, the framework will set out the competencies and skills that staff from different professional backgrounds will need in order to support people care and to link with other professionals and services to ensure all of a person's needs are met: The framework will recognise needs that require attention, such as support from a community or specialist mental health pharmacist to discuss medication choices and compliance: The community framework will also include examples of best practice information, including evidence-based community discharge processes. These will specifically reference the importance of considering a person '$ discharge destination and ongoing care needs and communicating with relevant teams to ensure that the necessary support is put in place in a timely manner to enable smooth transition. In the interim, NHS England has confirmed that it will undertake the following actions by the end of the year to address the issues noted in your report: NHS England will write to GP practices to make them aware of this issue and to consider what mechanism do or could employ to monitor the collection of antipsychotic medication prescriptions; NHS England will explore with NHS Digital what opportunities there are for primary care clinical systems to alert GPs around prescription collection issues for named patients and named and NHS England will work with NHS Improvement on communication to providers around making discharge letters explicit on medication risks that need to be monitored in primary care. [ this response is helpful. Thank you for bringing your concerns to our attention: bll JACKIE DOYLE-PRICE key- key - they for, special they drugs; hope '

Report sections

Investigation and inquest

On Sth February 2016 [ opened an inquest into the death of Daniel Young, then aged 30 years: The inquest concluded on 28th and 29th June 2018. The conclusion of the inquest was a narrative conclusion; the medical cause of death was shock and haemorrhage due to stab wound to the abdomen_

Circumstances of the death

Daniel Young was a fit and healthy university lecturer: On 19th January 2016, he was randomly attacked on his way to work: He sustained a fatal stab wound to the abdomen His attacker (ML) had been a patient of local mental health services He had suffered periods of psychosis He was known to be aggressive when psychotic. At the time of the attack, ML was living in the community with no secondary mental health follow up. He had been discharged to his GP and told to remain on his antipsychotic medication for at least 6 months and only reduce them slowly, if at all. He was told that stopping the medication may lead to a relapse of his psychosis_ ML stopped his antipsychotics soon after discharge from the CMHT. At the criminal trial ML was found guilty of manslaughter by reason of diminished responsibility:

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: 2018-0240
Date of report: 26 July 2018
Coroner: Shirley Radcliffe
Coroner area: London (Inner) West

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: 18 Nov 2018 (estimated).

Sent to

Department for Health

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.