David Buttriss

Coroner's concerns

AI summary

Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies hindered effective care.

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_ _ Mr Buttriss had contact with a number of health agencies in the weeks to his death including the Community Mental Health, Home Treatment team, GP , Out of Hours GP and Paramedics. It was clear from the evidence at inquest that There were Communication issues between the GP and mental health service_ The mental health services had requested a patient profile the GP on 14.5.16 which was not received. The Patient's GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when were contacted at the time of crisis The health care records for the GP and Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by on 25th April nor did the mental health workers have information about the appointment withl nor were they aware of the medication issues_ The Out of Hours GP did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th It was clear evidence of the Paramedic and prior from they the May. from the and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Buttriss on the night of 7th when he was in crisis_ The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the role of the Home Treatment Team Out of Hours provision

Responses

3 respondents

Devon Doctors

1 Mar 2018 PDF

Noted

Devon Doctors no longer provides out-of-hours services in Cornwall and has passed the report to the new provider. They reviewed the concerns in relation to their Devon services, noting that information sharing is partly outside their control but that clinicians have appropriate pathways to escalate concerns, including Community Mental Health Practitioners in their Clinical Assessment Service. A Rapid Reassessment Pathway for individuals with mental health needs discharged from secondary to primary care has been developed by Livewell Southwest. (AI summary)

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Dear Dr Carlyon Re: Regulation 28 related to Mr David Buttriss (deceased) Thank you for your letter dated 12/h January 2018 requesting action relating to your Regulation 28 report; to prevent future deaths_ Your letter was directed to Dr Dean Marshall, Medical Director for Cornwall Health. You are aware, as identified within report; that Cornwall Health (a subsidiary company of Devon Doctors) no longer provide the out of hours service within Cornwall and that this is now provided by partnership of Kernow Health CIC , Royal Cornwall Hospital NHS Trust and Vocare, under the name of Cornwall 111 Integrated Urgent Care Service. You sent a copy of the regulation 28 report to Kernow CIC and too have passed the responsibility to review the actions you have identified for Cornwall to the new provider; having shared these with Dr Dean Marshall who, while no longer Medical Director for Cornwall Health, continues in the role of Medical Director for the new service As Devon Doctors no longer provide any urgent care within the county of Cornwall we are unable to effect the potential changes you are seeking: However; as Devon Doctors provide the Integrated Urgent Care Service for the county of Devon the actions from your regulation 28 report have been reviewed by Dr Mark Eggleton, Medical Director. Dr Eggleton notes that some of your recommendations regarding information sharing are beyond the control of Devon Doctors but he is assured that our clinicians are able to make accurate assessments regarding risk, to the patient and others, and have appropriate pathways to escalate their concerns to local mental health services. In reality this often means the patient is referred to ED to see the liaison psychiatrist team, since mental health assessments in the home environment are even more difficult to arrange out of hours than they are in hours_ Further, Devon Integrated Urgent Care Service, in conjunction with Devon Partnership Trust;, have community mental health practitioners (CMHP) working within our Clinical Assessment Providing out-of-hours medical care for the NiS across the county Devon Doctors Ltd Company No. 05174987 . Company limited by guarantee and registered in England and Wales your they

Service, which supports direct access to mental health support for callers to urgent care with mental health issues. In addition Devon Doctors Group has had involvement with a serious incident, also related to suicide, and for which the inquest is pending: In part as result of this case, Livewell Southwest has developed a Rapid Reassessment Pathway for individuals with mental health needs who are discharged from secondary to primary care_ The pathway has been presented to, and agreed by, the Local Medical Council and provides a safety net whereby if patient was to relapse, they could re-access psychiatric services in timely way. trust that this response is satisfactory_

Cornwall NHS Trust NHS / Health Body

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Action Taken

Cornwall NHS Trust has implemented a new assessment service with designated administrators to manage referrals, and developed new Safety Plans for patients containing crisis information. The Trust is also reviewing the Out of Hours services and any changes will be communicated to external providers. (AI summary)

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Page 2

In addition Beth Ford, in her new role as Community Mental Health Nurse Consultant, has begun working with a number of local GP practices. This has involved meeting GPs to discuss the new assessment service; the role and remit of Community Mental Health Teams and ways to improve information sharing and raising patients of concern. This is an ongoing piece of work to continue to improve liaison between services.

2. To review the possibility of secure health record sharing between mental health agencies, Hospitals, GP’s and out of hours health agencies e.g. Out of Hours GP, Home Treatment Team and paramedic and Hospital Emergency Departments

The Trust already works with other agencies to allow secure health record sharing. Agencies are requested to complete an application form for access to RiO, the Trust’s electronic health record system. The application form is a standard form which requires specific information detailing the individual, their role, employing organisation and the legal basis for access as well as confirmation of Information Governance training. The Trust has allowed access to RiO to a number of agencies including Cornwall Council, acute hospitals and GPs.

3. To clarify to health professionals (and if possible to patients and public) the roles and responsibilities of each health agency especially outside normal working hours and weekends so that patients are referred to the correct agency and are aware of safety nets in place if their health deteriorates.

In direct response to your Regulation 28 report the Trust has changed the Trust’s internet page. There is now a designated section headed “I need help now” providing mental health crisis information. The internet page is accessible to all members of the public including patients and health professionals and provides information explaining the roles and responsibilities of daytime and out of hours mental health services as well as details of a number of helplines and resources available to support those in crisis. Contact telephone numbers are also provided for the Trust’s Home Treatment Teams and Community Mental Health Teams.

In addition new Safety Plans have been developed to be completed and provided to patients containing detailed crisis information for patients and their relatives, friends and carers. The plans confirm the name of team providing the care and the name of their care co-ordinator as well as the best number to contact the team and crisis numbers. The plan encourages carers to share any concerns and participate in the care and also explains that a “Nearest Relative” can speak to an Approved Mental Health Professional about their rights as a nearest relative. The plan is completed with the patient and sets out their warning signs; coping strategies and professionals or agencies to contact in a crisis.

The Trust is reviewing the Out of Hours services and this is likely to result in changes to the Home Treatment Teams within the next 6 months. Once changes have been confirmed the Trust plans to meet with external providers to confirm the changes and clarify the role of the Home Treatment Teams.

4. To consider GP’s making a routine follow-up after referral or signposting to other agencies to ensure that referral has been followed up and the outcome known.

Page 3

From the Trust’s perspective the outcome of an assessment with Adult Mental Health Services is confirmed in writing to GPs and on-going liaison work with GPs will also improve communication and information sharing.

In summary action has been taken by the Trust with the introduction of the assessment service; liaison work with GPs; changes to the Trust’s internet pages and the introduction of a patient Safety Plan. The Trust already has a mechanism in place to allow access to RiO. The Trust is taking action in reviewing the Trust’s Out of Hours services and any changes will be communicated to external providers.

I am truly saddened by the death of Mr Buttriss and I wish to extend my condolences to his family.

NHS England NHS / Health Body

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Action Planned

NHS England proposes to disseminate a reminder to GPs to safety net urgent mental health referrals, and to consider giving patients written guidance on what to expect and when following a referral. (AI summary)

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Dear Dr Carlyon, Re: Report to Prevent Future Deaths (Regulation 28) following the conclusion of the inquest into the death of David John Buttriss Thank you for your Regulation 28 Report to Prevent Future Deaths ("Report") following the inquest into the death of David Buttriss. would like to express sincere condolences to Mr Buttriss's family. In your report you have asked NHS England to consider several matters of concern to ensure to prevent future deaths As the first two points within section 6 are concerned with information sharing we will provide a response to both these points together: NHS England is committed to working with the National Data Guardian to encourage health and care practitioners to share information in the interests of patients_ There are clear guidelines that encourage information sharing such as the principles and recommendations published in the 2013 review of information governance in the health and care system ("To Share or Not to Share" ): This report was conducted by Dame Fiona Caldicott who has since been appointed to be the National Data Guardian: There are also obligations on clinicians under the common law duty of care to ensure that data is shared appropriately with colleagues, but much of this is dependent on the professional judgement of clinicians We understand that not all data is shared as there may be circumstances in which this could be detrimental to the health and wellbeing, however we would expect that these incidents are documented_ We recognise that there are many challenges across the NHS to support secure data and record sharing; and we are actively leading a number of initiatives to address this: For example, the Global Digital Exemplar ("GDE programme, led httpsIIWW9OV_Uklgovernmentlpublicationslthe-information-governance_ review High quality care for all, now and for future generations

by NHS England, will improve electronic information sharing as many parts of the service still rely on paper-based systems. This will join up and digitise the health systems so that clinicians have timely access to accurate patient information and equally patients will have better access to their records too The GDE programme will also support digitally advanced acute and mental health Trusts to share their learning and experiences with other NHS Trusts to ensure can also harness the use of digital technology and information sharing to deliver high quality care. NHS Trusts will receive support through funding and international partnership opportunities to become Exemplars over the next two to three and a half years. NHS Trusts participating in the GDE programme will also be required to support digital record-sharing with local partners across physical and mental health: They are expected to adopt appropriate technologies, implement standards and business processes which enable patient and service user information to be shared across care settings. In addition, NHS England is working with a number of Local Health and Care Record Exemplars to support the provision of safe integrated care across health and care settings The aim will be to establish a local record for authorised staff in different organisations to access permitted information about a patient's history of contact with the NHS and related care services. This may include information from 'physical health checks' for people with serious mental illness which NHS England is encouraging greater take up of: We have made progress on this with around 60 local information sharing initiatives underway, each aiming to share information across organisations such as GP , Acute and Social Care settings and across geographies as the patient moves. With regards to the third point within section 6, NHS England has set an ambition in the Five Forward View for Mental Health to ensure that community based mental health crisis and acute services are available 24/7 everywhere by 2021_ and to expand provision of 24/7 specialist mental health services in A&E and general hospitals_ NHS England has already published guidelines on the provision of urgent and emergency mental health provision in A&E general hospitals, and intends to publish guidelines in 2018/19 to clarify the pathways of care for urgent; emergency and acute mental health services in the community. This includes ensuring that anyone, including health professionals, police, family members are able to access timely, 24/7 specialist care for people with emergency mental health needs_ With respect to 4 within section 6 , GPs, as specialists in primary care medicine, have to manage risk and uncertainty in their day to day clinical practice There are established procedures in place in general practice to ensure urgent and important referrals and actions are followed up or "safety netted" to ensure a patient's care is not compromised by administrative failings. The Care Quality Commission ("CQC") as of its inspection regime review practices systems and processes High quality care for all, now and for future generations they will Year point part

The judgement when to "safety net" by arranging a follow up contact with the patient will be a clinical one, with the clinician balancing the benefits of an earlier review with the need to ensure the practice can provide sufficient access to other patients with acute or urgent health problems. GP IT systems already offer systems for GPs to use prompts and reminders for them to take an action to ensure patient has been contacted by appropriate specialist services. In response to this Report; NHS England proposes to disseminate a reminder to GPs to safety net urgent mental health referrals, reflecting in particular the inherent vulnerabilities associated with patients with mental health problems who may find it more difficult to engage with specialist mental health services when they are acutely unwell; and furthermore consider giving a patient written guidance on what to expect and when following referral, given the impact mental health problems have on concentration and hence memory_ this provides you with the assurance that NHS England is responding to the concerns raised and has taken action to improve the provision of mental health care services to patients:

Report sections

Investigation and inquest

An investigation was opened on 13th 2016 into the death of DAVID JOHN BUTTRISS who died on 9th May 2016 at his home address Western Meadows , Under Lane, Launceston. An inquest was opened on 16th 2016 and a full Inquest hearing was held between the September 2017 at Truro Municipal Buildings. The Inquest found the cause of death as 1a Massive haemorrhage 1b Penetrative trauma to the right neck and the conclusion was "Suicide"_

Circumstances of the death

David Buttriss had been aggressive towards his parents on the morning of the 9th May 2016 and produced a Stanley knife at the time and was threatening to kill himself. parents phoned the police at 10.21am While his father was on the phone to the police David stood at the top of the stairs on the landing and said "Call them off, Im not a danger to you or mum: They'Il take me away: Don't do this" David then cut himself at around 10.41 am and became unconscious. Despite medical assistance and resuscitation his father, the police and paramedics he was confirmed dead at 11.35 am. A hand written note was found in the rear of annotated book "Loving Someone with Border-Line Personality" stating 'Every night is a Friday night and every morning_is a Monday Morning: May 6-7th May His from

Love you all. So very sorry Dave X' He suffered from long term mental health issues which had deteriorated after he failed to rekindle a significant relationship in the weeks prior to his death: In addition the use of cannabis and the effect of an anaesthetic had adversely affected his mood. There had been input from his GP , the Community Mental Health Team and the Home Treatment team and out of Hours doctors and paramedic in order to address his deteriorating mental health

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action: 1 . To review the methods of requesting and obtaining relevant information on patient between health agencies for the purpose of treating a patient in timely manner e.g: Patient profile requests from mental health services mental health input summaries to GP especially at time of quick deterioration in healthlmental health or crisis. To review the possibility of secure health record sharing between mental health agencies, Hospitals, GP's and out of hours health agencies
e. g: Out of Hours GP , Home Treatment Teams and paramedic and Hospital Emergency Departments To clarify to health professionals (and if possible to patients and public) the roles and responsibilities of each health Agencies especially outside normal working hours and weekends so that patients are referred to the correct agency are aware of the safety nets in place if their health deteriorates 4_ To consider GP's making a routine follow up after referral or signposting to other agencies to ensure that referral has been followed up and the outcome know_

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