Source · Prevention of Future Deaths

Henry Heselton

Ref: 2018-0152 Date: 18 May 2018 Coroner: Caroline Topping Area: Surrey Responses identified: 1 / 1 View PDF

Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental health teams and GPs.

Date 18 May 2018

56-day deadline 2 Sep 2018 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental health teams and GPs.

View full coroner's concerns

1. The electronic mental health records were unclear. Vital information about Mr Heselton’s mental health history, including that he had attempted suicide in the past, was difficult to find. His most recent care plan did not record this. The information was not easy to extract for professionals needing to find information about a patient in a crisis.
2. There was a lack of communication between the mental health teams and the general practitioner. The fact that contact had been made by with both the acute and community mental health team was not shared with his General Practitioner. This left her without relevant recent history to inform her clinical judgement when she was contacted by on the 7th September 2016.

Responses

1 respondent

Southern Health NHS Foundation Trust NHS / Health Body

21 Jun 2018 PDF

Action Taken

Southern Health NHS Foundation Trust revised the Risk Summary Section in its electronic patient record in January 2017, requiring all staff to input risk information according to national guidance. The Acute Mental Health Team and Community Mental Health Team Standard Operating Procedures have been reviewed, and team managers have been instructed to ensure that staff communicate with GPs after triaging referrals and to regularly monitor that it is occurring. (AI summary)

View full response

Dear Ms Topping Regulation 28 Report Henry Heselton write further t0 the above issued on 21 2018, following the conclusion of the inquest into the death of Henry Heselton: note your areas of concern, which will address in turn, are as follows:
1. The electronic mental health records were unclear: Vital information about Mr Heselton's mental health history; including that he had attempted suicide in the past; was difficult to find: His most recent care plan did not record this_ The information is not easy to extract for professionals needing to find infomation about a patient in a crisis: It has been recognised, by the Trust, that our electronic patient record, RiO, supports the recording and sharing of vital clinical information; including risk, more effectively than the previous paper record system, including improved legibility: organisation, sharing and identification of information; However the system has faults and limitations, and information can be difficult to find. It is therefore subject to ongoing review so that it can be redesigned in a way which supports clinical practice The clinical workforce receives training and support to be able to use the system effectively- The concern that vital information has not being readily available has been accepted and action taken to remedy this_ There has been, since January 2017 (evaluated in April 2018) , a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors: demographic, background, clinical history, psychological and psychosocial factors and current context: The clinical assessment of these factors leads to management plan which will include a 'My Safety & Crisis Plan' (a collaborative approach to safety planning) This is monitored, and staff are prompted to complete or update the plans at regular intervals, and this should always happen when there is significant change in risk There has also been a review of the care planning process, and a Community Care Plan page developed (since January 2018) , where all care plans are inserted s0 that can be readily identified as well as the Risk summary: OUR VALUES Palients & people first Partnership Respect May key they

There was a lack of communication between the mental health teams and the general practitioner: The fact that contact had been made by Mrs Heselton with both the acute and community mental health team was not shared with his General Practitioner: This left her without relevant recent history to inform her clinical judgement when she was contacted by on the 7th September 2016. Safe and effective clinical care is dependent on appropriate information sharing with patient; carer, GP and other agencies and this includes assessment of risk and care planning: At the following times information should be shared with primary care: After referral to Mental Health Services to let the GP know of the triage process which will include a plan for assessment to occur and fhe timing of it or ofher advice or signposting (which did not accur 0n the occasion referred to) After each initial assessment with details of the assessment; including risk. Psychiatric out-patient appointments Discharge from inpatient services Care Programme Approach meetings: these are care planning meetings involving the patient; their family and the important services that are involved in the patients care, eg. Housing, social care, community teams, police: Communication should also occur when thereis a request to a GP for support with medication or physical health review. Electronic communication has being developed to allow access to CHIE (formerly the Hampshire Health Record) and GP summary patient records and is developed to allaw access for GPs to the mental health record But this does not mean that communication described above will be superseded To address the shortcomings in the care provided to Mr Heselton, these principles have been included in the review of tne Acute Mental Health Team and Community Mental Health Team Standard Operating Procedures, and the team: managers instructed to ensure that staff are 'aware of requirement to communicate with GPs after triaging referrals and to regularly monitor that it is occurring_ do hope that this letter provides you with the information: and assurance that you require regarding the measures that have 'been put in place. Please do not hesitate to contact me if you require any further information: Yours sincerelv Dr Nick Broughton FRCPsych Chief Executive Officer being the

Report sections

Investigation and inquest

An inquest into the death of Mr Henry James Heselton was opened on 7th October 2016 and resumed on 26th January 2018. It was concluded on 4th April 2018. I concluded that Mr Heslton died on the 28th September 2016 at Down Lane Guildford. and that the medical cause of his death was:

1a Hanging

Henry Heselton died at Down Lane, Guildford. He had suffered from paranoid schizophrenia for many years which had been controlled by medication. He had expressed suicidal ideation for many years. It is not possible to find what triggered the relapse of his mental health which led him to take his own life nor whether more proactive mental health support could have prevented his death. He hanged himself on the 28th September 2016. Conclusion as to death; Suicide

Circumstances of the death

Mr Heselton was born on the 30th January 1985. He obtained 2 degrees and worked as an audiologist at Royal Surrey Hospital in Guildford. He was a very conscientious young man. In 2008 he was diagnosed with paranoid schizophrenia. His mental health care was provided by a community mental health team from Southern Health NHS. He did not want any treatment to impact on his work. A care plan was put in place which accommodated his wishes and which relied on his Mother to be his carer. Mrs Heselton was authorised to liaise with mental health professionals on his behalf. Her contribution was regarded as an integral part of his care plan. In addition, Mr Heselton’s GP surgery made arrangement for Mr Heselton to have regular blood tests because of the medication he was taking. This involved him attending the surgery on a monthly basis and seeing one of the nursing staff. He saw his psychiatrist for annual reviews. He did not want a care co-ordinator.

On Sunday the 28th August 2016, on a bank holiday weekend, rang the East Acute Mental Health Team crisis team run by Southern Heath Trust. Her son was in crisis. She sought advice about medication. She said that she thought Mr Heselton might kill himself that day, he could be heard highly distressed in the background. The crisis team was one member of staff short that day. The mental health nurse practitioner answering the phone did not have time to read Mr Heselton’s medical records. She suggested ringing an out of hours GP. No follow up call was made to and the call was not subject to a multi-disciplinary discussion. Details of the call were forwarded to the community mental health team. They were not at work until the following Tuesday. Mr Heselton’s general practitioner, , was not notified of the call.

On Wednesday 1st September 2016 Mr Heselton’s psychiatrist, , called

. He was informed that Mr Heselton’s mental health had deteriorated but from the information provided by he did not regard Mr Heselton to be at significant risk. He made an appointment to see Mr Heselton on the 23rd September 2016 after he had had his blood test at the surgery. This call was not notified to said she thought Mr Heselton would not attend the psychiatric appointment.

On the 7th September 2016 Mrs Heselton called to discuss Mr Heselton’s mental health and ask about medication. From the information she was given did not think Mr Heselton was actively suicidal. That assessment was made without having been made aware of the 2 recent contacts with .

was therefore not able to make a fully informed decision about Mr Heselton’s treatment and was not able to undertake a fully informed risk analysis.

On the 23rd September 2016 Mr Heselton attended at the surgery to have his blood tested but did not attend his psychiatric appointment. On the 27th September 2016

was unable to contact Mr Heselton. She tried to call the police but did not use 999. She feared he had killed himself. The following day she was notified that Mr Heselton had not arrived for work. She called the police and Mr Heselton was found in a field off Down Lane Guildford. He had hanged himself. told the police he had been talking about killing himself for 4 days.

An investigation by Southern Health Trust concluded that there had been a missed opportunity to engage with Mr Heselton and to have a mental health assessment on the 28th August 2016. In addition, that it was essential that staff answering crisis calls familiarise themselves with the patient’s mental health records.

Professor Fox a Consultant Psychiatrist gave evidence as an expert at the inquest. In his view the 3 contacts with should have raised alarm about Mr Heselton’s mental state. More should have been done to engage and support and communication should have been better between the crisis team and the community mental health team, and with . He accepted that, given Mr Heselton’s reluctance to engage with mental health services, the decision whether to undertake a mental health assessment of Mr Heselton was a difficult one and may have undermined his therapeutic relationships with the mental health professionals.

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Report details

Reference: 2018-0152
Date of report: 18 May 2018
Coroner: Caroline Topping
Coroner area: Surrey

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: 2 Sep 2018 (estimated).

Sent to

Southern Health NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.