Source · Prevention of Future Deaths

Sara Moran

Ref: 2018-0133 Date: 28 Apr 2018 Coroner: Alan Wilson Area: Blackpool & Fylde Responses identified: 1 / 1 View PDF

Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.

Date 28 Apr 2018

56-day deadline 24 Jun 2018

Responses identified 1 of 1

Alcohol, drug and medication related deaths

Coroner's concerns

AI summary

Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.

View full coroner's concerns

1. Having reviewed the inquest evidence, and notably the evidence of referred to above, I informed the court that I would write this report. I am concerned that if mental health professionals are expected to provide care to an excessive number of service users – many of whom inevitably pose significant challenges – then there a genuine risk of future deaths arises as a result of this. Sara Moran had a history of drug and mental health problems. Although I did not find that the care afforded to Sara contributed to her fatal outcome this does not prevent me from writing this report. If mental health professionals are finding themselves struggling to provide the level of service that Service Users such as Sara require then such demands in my judgement inevitably pose a significant risk that one or more such Service Users may not receive the level of attention they need and with potentially fatal consequences.

At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.

Responses

1 respondent

Department of Health Central Government

12 Jun 2018 PDF

Noted

The Department of Health acknowledges concerns about capacity within mental health services, but emphasizes the responsibility of individual NHS Trusts for staffing levels and training. The response outlines existing CQC regulations, national guidance, and initiatives to improve access to psychological therapies and increase the mental health workforce. (AI summary)

View full response

From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health and Inequalities Department Department of Health and Social Care of Health 39 Victoria Street London SWIH OEU Our reference: PFD 1131236 Mr Alan Wilson HM Senior Coroner; Blackpool & Fylde Municipal Buildings Corporation St Blackpool FYI IGB 12 June 2018 Jea U W 0 Thank you for your letter of 28 April to the Minister of State for Health about the death of Ms Sara Antonia Moran_ Lam responding as Minister with portfolio responsibility for mental health: I have noted carefully the circumstances you have outlined around Ms Moran 's death and your concern about capacity within mental health services_ I should firstly point out that individual NHS Trusts are responsible for the number and of staff employ and for ensuring there is a sufficiency of staff trained and competent to carry out their duties. Appropriate staffing levels are already a core element ofthe Care Quality Commission's (CQC $) registration regime underpinned by legislation. AIl providers of regulated activities must be registered with the CQC and meet the registration requirements_ The 16 safety and quality requirements set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 include a requirement for the deployment of sufficient numbers of suitably qualified, competent, skilled and experienced persons_ In July 2016, the National Quality Board published * Supporting NHS providers to deliver the right staff with the right skills, in the right place at the right time: Safe, sustainable and productive staffing This safe staffing improvement resource provides an updated set of expectations for nursing and midwifery care sta) to https /Lwww englandnhs uk wp-contentuploads/2013/04/ngb-guidancepdf type they ffing,

help NHS provider boards make local decisions that will support the delivery of high quality care for patients within the available staffing resource. NHS Improvement is leading the national programme to develop and deliver NHS safe staffing improvement resources for specific care settings, including mental health: The National Quality Board published Safe, sustainable and productive staffing: An improvement resource for mental health in January 2018. The resource outlines systematic approach for identifying the organisational, managerial and environmental factors that support safe staffing: It makes recommendations for monitoring and action if not enough staff are available to meet people's needs. On the matter of capacity within crisis resolution and home treatment teams (CRHTTs) ifically, we do recognise that, at present, further investment and development is required to ensure that all CRHTTs are adequately resourced to be able to offer safe, therapeutic crisis assessment and home treatment: Where are resourced and operating in line with the evidence base, the evidence base demonstrates that are able to achieve improved outcomes and experiences for people. NHS England is committed to ensuring that by 2021 all CRHTTs are resourced to operate on a 24/7 basis, with enough staff to deliver intensive home treatment in line with the evidence base. This is being supported by new data collections to provide transparency about the variation among clinical commissioning groups in terms of the resources are providing to CRHTTs and other crisis and acute mental health services_ Delivering the expansion of CRHTTs is critical both to alleviate the suffering of individuals in crisis, but also to alleviate pressure on acute in-patient mental health care and tackle inappropriate and expensive acute out of area placements Further information about the delivery of this commitment can be found in ` Implementing the Five Forward View for Mental Health published in July 2016. On workforce, we acknowledge that the mental health workforce is pressures and this is why Health Education England (HEE), in conjunction with NHS England and NHS Improvement; published *Stepping Forward to 2020/21: Mental Health https limprovement nhs uk-resources/safe-staffing-mental-health-services https: WWW. englandnhs uk wp-content/uploads/2016/07/fvfv-mhpdf taking specif they they large `- they Year facing

Department of Health Workforce Plan for England' in July 2017. The mental health workforce plan is a fully-researched and considered response to the commitments made in both the `Five Year Forward View for Mental Health'5 and Future in Mind"6_ Working with the Royal Colleges, trainees and mental health charities, HEE will develop an urgent action plan to attract and retain more clinicians to work in mental health services and psychiatry. HEE will also commission focus groups and polls of potential and existing trainees So it can better understand the obstacles, increase the support offered to them and improve the profile and attractiveness of careers in mental health. The expansion of medical student places by 1,500 in England creates opportunities to increase the numbers of trainee psychiatrists. The mental health workforce plan commits HEE to work with the Royal College of Psychiatrists to ensure that the allocation of these places is to universities with a proven track record in producing psychiatrists. HEE also has plans to increase the exposure to psychiatry during training (which can help increase applications for the specialty). HEE has already increased the number of doctors in the Foundation Programme a four month psychiatry post to 50 per cent. For the longer term, the plan commits to exploring with the Medical Schools Council changing entry requirements for medical degrees so that Psychology A level is considered of equal merit to increase the of applicants likely to go on to become psychiatrists: Specifically, the Five Year Forward View for Mental Health sets the objective that Improving Access to Psychological Therapies (IAPT) services should see 1.5 million people a year by 2020, with 75 per cent of people accessing care within six weeks and 95 per cent within 18 weeks, with particular improvements in access for people from black and minority ethnic groups, people with a learning disability, older people, and women in the perinatal period. https: /Lwwwheenhs uklsites/default files/documents/Stepping%2Oforward%20to%20202021920 %2OThe"o2 Omental%2Ohealth%2Oworkforce%o2 Oplan%/2Ofor%/2Oenglandpdf https: WWWenglandnhs uklwp-content/uploads/2016/02 MMental-Health-Taskforce-EYEV-finalpdf Suttps /lassetspublishing service govuklgovernmentuploads/system/uploads/attachment_data file/4L4024 Childrens_M ental_Health doing pool pdf

This will require the training of an additional 4,500 therapists between 2016 and
2020. A substantial part of this expansion will rely on a move to further integrate mental and physical health services through the development of Integrated IAPT Services. This is reflected in the General Practice Forward View with the objective that there will be 3,000 therapists co-located in primary care by 2020. [ hope the information I have provided is helpful. Thank you for bringing your concerns t0 our attention. U2 JACKIE DOYLE-PRICE https:/ WWW england nhsuk wp-content uploads/2016/04gpfv pdf

Report sections

Investigation and inquest

I conducted an investigation into the death of Sara Antonia MORAN, known as Sally, and the inquest that was held over the course of two days on 9th and 10th April 2018.

The medical cause of death was 1a morphine toxicity

The conclusion of the Coroner as to the death: DRUG RELATED

In paragraph 3 of the Record of Inquest I recorded as follows:

Sara Moran, known to her family as Sally, had a history of mental health problems and drug abuse. At approximately 1030am on Saturday 22nd April 2017 police attended at her home address after a concern was raised for her welfare. The property was found to be secure and entry was forced. Sally had made efforts to barricade herself into her bedroom where she was located on her bed and in close proximity to a large number of blister packets of medication. The last known communication with her was no later than 0730 hours on Tuesday 18th April 2017. She had most likely been deceased since at least that afternoon. A subsequent post mortem examination confirmed she had died from the effects of voluntarily ingesting a large quantity of morphine.

Circumstances of the death

Sara had a history of mental health issues but had not been detained in a mental health facility nor been a voluntary patient in such a facility for some time. Historically she was known to fail to engage with mental health services and had previously been discharged from services regularly. At the time of her death she was diagnosed with Recurrent Depressive Disorder (F.33) and Mental & Behavioural Disorder due to Multiple Drug Use (F.19).

On 5th April 2017 her General Practitioner, with whom she had a good relationship, referred her for an urgent assessment of her mental health when she presented as paranoid and at one point threatened to throw herself in front of a train A mental health professional was able to speak to her Mother later that day and decided she could spend the night at her Mother’s address on the understanding that she attend a previously planned appointment for an assessment scheduled for the next day. This was regarded as a reasonable decision. However, she did not attend and could not be contacted.

After a Multi-Disciplinary Meeting held on 7th April 2018 she was sent a letter asking her to contact the team if she wanted an assessment and indicating that In the event no contact was received from her during the following ten day period she would be discharged from mental health services and back to her GP.

On 10th April 2017 mental health services confirmed there was some contact with Sara and arrangements were made for an appointment on 13th April 2017 but she did not attend.

On 15th April 2017 the mental health team were contacted by the police who were with Sara at the time and the police were concerned about leaving her on her own although she had not expressed any suicidal intent. She would not go to hospital for assessment. That conversation appears to have concluded on the basis that the police were under the impression that the mental health professionals would be in contact with Sara but the Deputy Team Leader with whom they spoke told the inquest she had understood that Sara had expressed suicidal thought and that the police had called for an ambulance which would take her to hospital where she would then be assessed. I preferred the police version on this disputed piece of the evidence.

The mental health team tried to make contact with her but she again failed to engage. There was no further contact with her. Ultimately she was reported as missing by a concerned neighbour who had last seen her on the morning of the 18th April 2017. By the morning of the 22nd April 2017 the police felt it necessary to force entry to her property where she was found deceased. It was determined at the inquest that although a letter felt to be in her handwriting was found in her property which may be interpreted as an indication of intent to harm herself it was undated and may not have been written around the time of her death. The criminal standard of proof was not satisfied to the extent that the Coroner could be sure beyond a reasonable doubt Sara intended to take her own life.

During the inquest evidence was heard from a , an Investigation and Learning Specialist who had performed the role of Investigation Lead as regards the Lancashire Care NHS Foundation Trust post incident review. His evidence was constructive. He informed the inquest that in his view at the time of the above events pertaining to Sara Moran the Crisis Resolution and Home Treatment Team staff were trying to service the needs of too many Service Users when taking into account the numbers of staff available and that this over capacity would in his view have affected the quality of the service afforded to Sara Moran.

Copies sent to

Chief Executive, Lancashire Care NHS Foundation TrustChief Executive, Blackpool Council

Inquest conclusion

Sara Moran, known to her family as Sally, had a history of mental health problems and drug abuse. At approximately 1030am on Saturday 22nd April 2017 police attended at her home address after a concern was raised for her welfare. The property was found to be secure and entry was forced. Sally had made efforts to barricade herself into her bedroom where she was located on her bed and in close proximity to a large number of blister packets of medication. The last known communication with her was no later than 0730 hours on Tuesday 18th April 2017. She had most likely been deceased since at least that afternoon. A subsequent post mortem examination confirmed she had died from the effects of voluntarily ingesting a large quantity of morphine.

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Report details

Reference: 2018-0133
Date of report: 28 April 2018
Coroner: Alan Wilson
Coroner area: Blackpool & Fylde

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: 24 Jun 2018.

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.