Source · Prevention of Future Deaths

Barbara Ellis

Ref: 2018-0038 Date: 2 Feb 2018 Coroner: Katy Skerrett Area: Gloucestershire Responses identified: 0 / 2 View PDF

A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.

Date 2 Feb 2018
56-day deadline 2 Aug 2018 est.
Responses identified 0 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.
View full coroner's concerns
Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ  Tel 01452 305661    |    coroner@gloucestershire.gov.uk  The MATTER OF CONCERN is as follows. – The Cross border provision of care - whether patients can access services adequately when they have a GP in one County, and pay Council tax to another.

In this case Mrs Ellis had a GP in Herefordshire, but paid Council Tax to Gloucestershire. This meant that her healthcare was being provided by Herefordshire Commissioners, and her social care from Gloucestershire Social Services. This resulted in her being unable to access therapeutic services from either commission.

Report sections

Investigation and inquest
On the 24th April2017 I commenced an investigation into the death of Barbara Caroline Ellis. The investigation concluded at the end of the inquest on the 25th January 2018. The conclusion of the inquest was suicide. The medical cause of death was 1A multiple injuries 1B
Circumstances of the death
This 52 year old lady had a significant history of physical and mental health difficulties. Following the death of her husband in 2012 she had really struggled with her loss. From 2014 she began accessing mental health services. Despite receiving support her mental state remained very fragile and she made multiple attempts to take her life. In 2017 she had been reviewed by her Psychiatrist and her GP. April was the anniversary of her husband’s death and her care package was increased to reflect this. On the 4th April she saw her support worker. Mrs Ellis was making future orientated statements and gave no indication that she was planning on taking her life. She also spoke to her daughter on the telephone at approximately 5.30 pm and again no indication was given. At some point during the evening Mrs Ellis made her way to the overbridge located near to Bromsberrow Heath between junctions 2 and 3 of the M50. She tied a ligature to the bridge, and jumped off it impacting with the carriageway below and suffered multiple injuries. Mrs Ellis had left suicide notes on her person and at her home address. Her body was discovered by highway workers. She was transferred to the regional trauma centre, and investigations soon revealed the extent of her injuries. Clinicians advised that she was not fit for operative intervention, and brain stem testing was carried out. Mrs Ellis was pronounced deceased at 13.25 hours on the 6th April 2017.
Copies sent to
, Acting Chief Executive of the 2gether NHS Foundation Trust, Rikenel Headquarters, Montpellier, Gloucester, GL1 1LY

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2018-0038
Date of report
2 February 2018
Coroner
Katy Skerrett
Coroner area
Gloucestershire

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Aug 2018 (estimated).

Sent to

Gloucestershire Clinical Group
Herefordshire Clinical Commission Group

Source links