Source · Prevention of Future Deaths

Adrian Jennings

Ref: 2018-0111 Date: 19 Apr 2018 Coroner: Alison Mutch Area: Manchester (South) Responses identified: 3 / 5 View PDF

Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.

Date 19 Apr 2018

56-day deadline 12 Aug 2018 est.

Responses identified 3 of 5

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.

View full coroner's concerns

1. The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust; which impacted on information sharing between professionals involved in his care;
2.there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a on the mental health ward; need for a type of mental health support service had been identified by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service; and
4. Tameside Hospital cannot change their electronic booking in/triage system to allow them to include drop down boxes for key information such as the fact that Police Officers have brought an individual to the Hospital because it is a national IT system: Any trust operating the Lorenzo system will struggle to capture this his key point stay information at booking in

Responses

3 respondents

Tameside Glossop CCG NHS / Health Body

12 Jun 2018 PDF

Noted

Tameside and Glossop CCG acknowledges the need to expand mental health support and is investing in additional services, but does not recognize a gap in provision for individuals with high levels of needs like Mr. Jennings as they consider them covered by existing secondary care services. They will follow up on the other concerns with Pennine Care Foundation Trust through quality and performance monitoring. (AI summary)

View full response

Dear Ms Mutch,

Thank you for your report dated 19/04/2018, which outlined the actions to be taken as per Regulation 28 regarding this tragic case.

We are responding to Point 3 – A need for a type of mental health support service by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service.

The Tameside and Glossop Strategic Commissioning Board has recognised the need to develop and expand mental health support and is in the process of investing in additional services, details of this can be found in the outline plan attached. We do not, however, recognise a gap in provision for a person with high levels of needs such as Mr Jennings. People with levels of need such as those outlined in your report are covered by the secondary care services we commission from Pennine Care NHS Foundation Trust.

We have also taken note of the other concerns raised in your report in relation to Pennine Care Foundation Trust and will follow these up with the Trust through our quality and performance monitoring.

Please contact us if you require any further information.

NHS England NHS / Health Body

PDF

Action Taken

NHS England notes the concerns and describes actions taken to address disparate IT systems (Global Digital Exemplar programme), joined-up discharge plans (national framework), and capturing when police bring in individuals (updated Emergency Department module in Lorenzo with mandatory data collection fields). (AI summary)

View full response

Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths following an inquest concerning the death of Mr Adrian Jennings Thank you for your Regulation 28 Report to Prevent Future Deaths ("Report") dated 19"h April 2018 concerning the death of Mr Adrian Jennings on 10"h December 2016. would like to express my deepest condolences to Mr Jenning's family: Your report concludes Mr Jennings's death was a result of drug toxicity. Following the inquest you raised concerns in your Report to NHS England regarding disparate IT systems impacting on information sharing, the ability of primary and secondary mental health services to provide a joined up discharge plan, mental health support services not being commissioned, and the inability to capture that police officers had brought an individual into the hospital as are operating a national IT system: have noted that Regulation 28 letter has also been sent to the mental health trust directly involved in Mr Jennings's case, and will leave it to the trust to address your concern regarding mental health support services not being commissioned: will only address the other three concerns in this letter. In relation to your first concern; we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps taken, led by NKS England. NHS England is leading a Global Digital Exemplar programme that is designed to join up and digitise health systems so that clinicians have more timely access to accurate information, and patients are provided with better access to their records Digitally advanced acute and mental health trusts are being supported to become Global Digital Exemplars, and will share their learning and experiences to enable other NHS trusts to deliver high quality care, efficiently, through the use of world-class digital technology and information. The trusts will receive support through funding and international partnership opportunities to become Exemplars over the next two to three and a half years. Acute and mental health trusts participating in the Global Digital Exemplars programme are required to support digital record-sharing with local partners across physical and mental health. are expected to adopt appropriate technologies, implement standards and business processes which will enable patient and service user information High quality care for all, now and for future generations they your being They

to be shared across care ettings. Supported by appropriate data sharing agreements, this will ultimately enable care professionals to receive notifications and alerts, view correspondence and test results, facilitate access to health and care records across localities, as well as supporting reciprocal communications between multi-disciplinary and multi-agency teams: As an example, there are a set of "interoperability" requirements that have been placed on the exemplars include the ability for Global Digital Exemplars to share mental health discharge summaries electronically: To further inform this work, there has also been specific activity led by the NHS England Mental Health team and Interoperability teams on identifying pathways of care for mental health and the information sharing requirements. This enabling the standards to then be developed to support the sharing of information. In addition, and building on this provider digitisation is the specific focus on enabling access t0 pertinent information from across venues of care There has been progress made on this within the service with around 60 local information sharing initiatives that aim t0 share information across GP, Acute and Social Care settings. Building on this, NHS England will be working with a number of Local Health and Care Record Exemplars that will focus on establishing a local longitudinal record available in their areas to enable authorised staff to access permitted information about a patient's history of contact with the NHS and related care services in order to support the provision of safe, integrated care. Importantly, these exemplars will be required to work to nationally published interoperability standards so that pertinent information can be accessed as a patient moves between organisations and geographies. They will also co-develop and highlight best practise in professional and public engagement; information governance and benefits realisation as many of the barriers of information sharing are not just technical. The aim is for all authorised clinicians within the scope of a Local Health and Care Record Exemplar to have ready access to patient shared care records, regardless of the setting: Exemplars will share their learning to support progressive implementation in other localities across the country. note your second concern regarding the ability of primary and secondary mental health services to provide a joined up discharge plan: NHS England believes that strong communication; between health care professionals, with individuals receiving care, and with their families and carers is crucial to delivering safe, effective acute mental health care pathways. This communication is particularly important when individuals are transitioning between teams or services and for ensuring a robust discharge plan is in place: To support improved discharge coordination, we are intending to publish best practice information later this year which draws on examples of areas that already have robust, evidence-based discharge processes in place. This specifically references the importance of considering a person's discharge destination and ongoing care needs early on in their admission and communicating with the relevant community teams to ensure that the necessary support is in place in a timely manner t0 enable smooth transition: With the patient s agreement; their family, carers and significant others should be engaged throughout their care, be properly supported and involved in care decisions from the very start and given information about the care plan, discharge decisions and changes to treatment: NHS England is also developing a framework in 2018/19 for Community Mental Health Services which will articulate models of improved joint working between primary and secondary mental health services. This will support teams to work together to plan High quality care for all, now and for future generations key key put

individuals' care holistically and with access to all the relevant information, particularly important for people transitioning between services NHS England will be consulting on the framework later this year: Timely follow-up after discharge from a mental health inpatient admission is particularly important to ensure a person is continuing to receive the support need. Mental health services currently adhere to a standard of ensuring follow-up from inpatient care settings within seven of hospital discharge, however, many services aim to complete follow-up by day 2 or 3 post discharge, in a face-to-face meeting where possible_ have consulted with NHS Digital in relation to your concern about the trust being unable to capture that an individual had been brought in by police officers because were operating Lorenzo, a national system. This function was not available in 2016 but the Emergency Department (ED) module has recently been updated and incudes mandatory data collection to fulfil the Emergency Care Data Set (ECDS) requirements (please see https Ilww england nhs uklounorkltsdlec-data-setl) The ED module now provides drop-down options for 'mode of arrival' with selections from an ECDS compliant list which includes 'police transport'. This is a mandated entry field. Similarly, there is a mandated field for 'Attendance Source' which includes ECDS compliant selection options and includes Custodial Services; prison: Custodial Services; detention centre and Police servicelforensic medical officer. There is also a non-mandatory free text facility which enables users to record 'Accompanied by' according to local policy and practice. This can be used to add for example, an officer's name and / or a relative accompanying the patient: These functions are part of the core Lorenzo ED module and are therefore standard within the current build: 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 Central Government

PDF

Noted

The Department of Health acknowledges the concerns raised and refers to national policy expectations and guidance, including the Mental Health Act 1983 Code of Practice and the Global Digital Exemplar programme. It also mentions the Healthcare Safety Investigation Branch's investigation into care for patients with mental health problems in emergency departments. (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 Your reference: 6022/CLB Our reference: PFD 1129434 Ms Alison Mutch OBE HM Senior Coroner; Manchester South Coroner' $ Court 1 Mount Tabor Street Stockport SKI 3AG June 2018 Ja Au Hutzl Thank you for your letter of 19 April to the Secretary of State for Health and Social Care about the death of Mr Adrian Jennings I am responding as Minister with portfolio responsibility for mental health. Your Report details a number of matters of concern, most of which are for the local NHS to address and I hope you find the responses from the Pennine Care NHS Foundation Trust; the Tameside and Glossop Integrated Care NHS Foundation Trust and NHS Tameside Clinical Commissioning Group (CCG) helpful. However; I will take this opportunity to make clear the national policy expectations in relation to the issues you have raised: It was concerning to read the difficulties Mr Jennings and his family experienced in understanding the plan for provision of support in the community and I note that you found it probable that the lack of effective support and communication in relation to the support plan contributed to Mr Jennings's death. The Mental Health Act 1983 Code of Practice whilst being statutory guidance for providers of services under the Act; should be observed as best practice by all commissioners and providers of services to people who may become subject to the Act. We revised the Code of Practice in 2015 and set out guiding principles to https: WWW gOV ukgovemmentlpublications code-of-practice-mental-health -act-J983

improve the care for patients The principles include mental health providers involving patients' carers and families in decisions about their care. The Code of Practice also makes it clear that we expect multi-disciplinary teams involved in care planning and discharge to include all relevant professionals and agencies which may be involved in a person'$ care. Further work is underway to support improved discharge coordination with the planned publication of best practice guidance for robust, evidence-based discharge processes. In addition, NHS England is developing a framework for community mental health services on models ofjoint working between primary and secondary mental health services. [understand further information on these initiatives is included in NHS England's response to your report. [am also advised that NHS England's response explains that mental health services are expected to adhere to a standard of_ ensuring follow-up inpatient care settings within seven of hospital discharge. This provides an important opportunity to ensure a person is continuing to receive appropriate support. You raise two matters of concern relating to IT, firstly on the lack ofa single IT system across the Pennine Care NHS Foundation Trust and its impact on patient information sharing: We recognise there are challenges across the service in enabling secure record sharing and there a number of steps being taken to address this, led by NHS England. Iwill leave it to NHS England to advise on the work currently underway around the Global Digital Exemplar Programme and the Local Health and Care Record Exemplars that are designed to join up and digitise health systems, providing clinicians with timely access to patient clinical information. On the matter of the Lorenzo system, [ can confirm that since 2016, functionality has been developed to enable the capture of the mode of arrival of the patient (such as with police assistance) , with the addition of a free text facility where relevant information can be captured in accordance with local policy and practice. These functions are part of the core Lorenzo emergency department module and are standard within the current build: Finally, you may wish to be aware that the Healthcare Safety Investigation Branch (the HSIB?) is conducting an investigation into the provision of care to patients who present at emergency departments with mental health problems hups: www hsib org ukl from days

Department of Health officials have made enquiries with the HSIB and I am informed there are similarities in the circumstances surrounding Mr Jennings' death and the reference case utilised by the HSIB in its investigation. The investigation has identified four areas of concem: The risk assessment process for patients suffering a mental health crisis attending an emergency department; Access to appropriate mental health professionals for adults attending an emergency department; Is the emergency department a 'Place of Safety' for an adult experiencing mental health crisis; and How information is shared between different disciplines within the same Trust: Completion of the investigation is anticipated in the Autumn: At present; the HSIB is not able to share further information. However; the HSIB would like to extend an invitation to talk you through the investigation findings once concluded if that would be helpful. If you wish to take up this invitation, please contact the HSIB directly. [ hope the information I have provided is helpful. Thank you for bringing your concems t0 our attention: Jakluo JACKIE DOYLE-PRICE My being - key-

Report sections

Investigation and inquest

On 16th December 2016 commenced an investigation into the death of Adrian Jennings . The investigation concluded on the March 2018 and the conclusion was a narrative one of Drug-related death contributed to by a failure to put in place and communicate a effective support plan following discharge from hospital. The medical cause of death was drug toxicity CIRCUMSTANCES OF THE DEATH Adrian Jennings had a history of mental health issues and attempts at self-harm: He was admitted to Taylor Ward following a presentation at Tameside General Hospital in October 2016. During his on Taylor Ward he and his family expressed concerns in relation to support in the community and the consequences of a lack of support: In particular that he would use to cope if not supported in the community: Following his discharge the Home Treatment Team (HTT) visited him on 1st December 2016 and Sth December 2016. On Sth December 2016 he was told that 12th December was to be the last visit. There was no communication of the support he would receive following that visit. Attempts on 9th December 2016 by his family to 22nd stay drugs likely understand the support plan were unsuccessful: Communication between the Pennine Care Teams involved was poor and hampered by the use of different I.T systems. There was a failure to effectively communicate with Adrian Jennings and his family: It is probable that the lack of effective support ad communication in relation to the support plan contributed to his death: On the 9th December 2016 and in the absence of a clear support plan when attempts to support to obtain any clear information had been unsuccessful Adrian Jennings took a cocktail of drugs and alcohol. He was found by Greater Manchester Police outside Costcutters at 02:40 on 1Oth December 2016. Concerned that he had taken an overdose and about safety he was taken by Greater Manchester police officers to Tameside General Hospital: At booking in there was a failure to record information by the staff. This meant there was a missed opportunity to record how high risk he presented. He left Tameside General Hospital before triage: His absence was not reported to Greater Manchester Police because the policy had a gap which meant that high risk absconding between booking in and triage were not reportable: It is possible that this contributed to his death: Adrian Jennings subsequently went to a friend' s address on the morning of 1Oth December 2016 where he was seen to go into a deep sleep. That evening he was seen to be no longer breathing: He was taken by ambulance to Tameside General Hospital and pronounced dead on 1Oth December 2016. Post mortem toxicology showed a fatal cocktail of drugs in his system: It is unclear at precisely what all the drugs were ingested. CORONER'S CONCERNS During the course ofthe inquest, the evidence revealed matters giving rise to concern: In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows.
1. The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust; which impacted on information sharing between professionals involved in his care;
2.there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a on the mental health ward; need for a type of mental health support service had been identified by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service; and
4. Tameside Hospital cannot change their electronic booking in/triage system to allow them to include drop down boxes for key information such as the fact that Police Officers have brought an individual to the Hospital because it is a national IT system: Any trust operating the Lorenzo system will struggle to capture this his key point stay information at booking in 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. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 14th June 2018. /, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report tothe Chief Coroner and to the following Interested Persons namely Mother of the deceased, who may find it useful or of interest am also under a to send the Chief Coroner a cOpy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Alison Mutch OBE HM Senior Coroner 19/04/2018 days duty

Circumstances of the death

Adrian Jennings had a history of mental health issues and attempts at self-harm: He was admitted to Taylor Ward following a presentation at Tameside General Hospital in October 2016. During his on Taylor Ward he and his family expressed concerns in relation to support in the community and the consequences of a lack of support: In particular that he would use to cope if not supported in the community: Following his discharge the Home Treatment Team (HTT) visited him on 1st December 2016 and Sth December 2016. On Sth December 2016 he was told that 12th December was to be the last visit. There was no communication of the support he would receive following that visit. Attempts on 9th December 2016 by his family to 22nd stay drugs likely understand the support plan were unsuccessful: Communication between the Pennine Care Teams involved was poor and hampered by the use of different I.T systems. There was a failure to effectively communicate with Adrian Jennings and his family: It is probable that the lack of effective support ad communication in relation to the support plan contributed to his death: On the 9th December 2016 and in the absence of a clear support plan when attempts to support to obtain any clear information had been unsuccessful Adrian Jennings took a cocktail of drugs and alcohol. He was found by Greater Manchester Police outside Costcutters at 02:40 on 1Oth December 2016. Concerned that he had taken an overdose and about safety he was taken by Greater Manchester police officers to Tameside General Hospital: At booking in there was a failure to record information by the staff. This meant there was a missed opportunity to record how high risk he presented. He left Tameside General Hospital before triage: His absence was not reported to Greater Manchester Police because the policy had a gap which meant that high risk absconding between booking in and triage were not reportable: It is possible that this contributed to his death: Adrian Jennings subsequently went to a friend' s address on the morning of 1Oth December 2016 where he was seen to go into a deep sleep. That evening he was seen to be no longer breathing: He was taken by ambulance to Tameside General Hospital and pronounced dead on 1Oth December 2016. Post mortem toxicology showed a fatal cocktail of drugs in his system: It is unclear at precisely what all the drugs were ingested.

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.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2018-0111
Date of report: 19 April 2018
Coroner: Alison Mutch
Coroner area: Manchester (South)

Responses identified

Responses identified 3 of 5

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Aug 2018 (estimated).

Sent to

Pennine Care NHS Trust

NHS England

Tameside Clinical Commissioning Group

Tameside General Hospital

for Health

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.