Source · Prevention of Future Deaths

Linsay Bushell

Ref: 2017-0137 Date: 25 Apr 2017 Coroner: Andre Rebello Area: Liverpool and Wirral Responses identified: 1 / 2 View PDF

A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder was identified.

Date 25 Apr 2017

56-day deadline 7 Nov 2017 est.

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Jury from the

The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area. The Jury found: Para 3 Linsay Bushell was certified as having died on the evening of 13th October; 2014. at the Liverpool University Hospital: Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014, The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation. Linsay put herself in position in which she was found however her intention was unclear. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broadoak Unit in the time leading up to her death_ The risk was managed adequately and effectively during Linsay's period as an in-patient We the jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made In the Trust Position Statement Mersey Care considers the death of any service user with the Utmost seriousness and care. As an organisation it is committed to providing a high standard of care t0 service users generally: If, in connection with any patient under its care _ mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them: Following the death of Linsay Bushell on 13th October 2014,Mersey Care instigated an investigation into her death, including the wider circumstances of her ~death, to find out whether there were shortcomings in the care provided to Linsay and, if SO, devise ways of improving practice_ That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer Its Terms of Reference were agreed by the Trust Board and were deliberately wide s0 as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigators report was provided to Mersey Care Trust Board in December 2015. Following the internal investigation, the Trust Board instructed the Chief Operating Officer of the Local Services Division to consider the report Of the internal investigation and undertake her own review and appraisal of the circumstances of the death; She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material: The Trust is committed to transparency and accountability: The purpose of this Position Statement is to advise the Court and Linsay's family of the Trusts response to the work which has been undertaken internally by Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that; by

Responses

1 respondent

Department of Health Central Government

1 Aug 2017 PDF

Action Taken

NHS England is investing in psychological therapies for people with personality disorders and developing guidance on high-quality services. Mersey Care NHS Foundation Trust has established a Personality Disorder Hub, devised Borderline Personality Disorder Guidelines, and provided nurse training, among other improvements. (AI summary)

View full response

Dear Mr Rebello,

Thank you for your letter of 26 April 2017 to the Secretary of State for Health about the death of Ms Linsay Bushell. I am responding as the Minister with responsibility for mental health at the Department of Health. I am grateful to you for allowing my officials additional time to finalise our response.

I was very saddened to read of the circumstances surrounding Ms Bushell’s death. Please pass my condolences to her family and loved ones.

You issued your Report to NHS England, alongside the Secretary of State for Health, and I understand Professor Sir Bruce Keogh replied to you on 21 July.

As you will know, NHS England is responsible for overseeing the commissioning of health services in England. As part of the Five Year Forward View for Mental Health, published in February 2016 (www.england.nhs.uk/mental- health/taskforce/imp/), NHS England committed to investing money to increase access to psychological therapies for people with diagnoses of personality disorder. In addition, NHS England are working to develop and publish guidance on what constitutes high quality services for people with diagnoses of personality disorder and this will include evidence based pathways within community mental health services.

I hope these commitments go some way to providing assurance to you, and Ms Bushell’s family, that action is being taken to improve this area of mental health care.

You have noted within your Report that Mersey Care NHS Foundation Trust’s internal review team highlighted a national view that admissions to hospital for people with borderline personality disorder may be counter-productive to improving their mental state.

The National Institute for Health and Care Excellence (NICE) published the Borderline personality disorder: recognition and management guideline in 2009 (www.nice.org.uk/guidance/cg78).

It states that inpatient referral for a person with borderline personality disorder should only be considered where the management of crises, such as significant risk of harm to self and others, cannot be effectively managed in the community or where someone is detained under the Mental Health Act 1983. If admitted to hospital, the guideline is clear that this decision should be made with a clear understanding of the potential benefits and risk of the admission. Care should also be supported by the Care Programme Approach which should be reviewed regularly.

Your Report details the action taken by the Mersey Care NHS Foundation Trust to learn from Ms Bushell’s death in developing therapies for patients with a diagnosis of personality disorder, in hospital and importantly, in the community, in Merseyside and Lancashire.

In particular, the Trust has taken steps to enhance the understanding and treatment for patients with personality disorders. This includes the establishment of a Personality Disorder Hub that is intended to co-ordinate and manage the care of patients with personality disorders in the community, limiting the need for hospital admissions through close collaborative, multi-disciplinary working. The care given is psychology based and targeted at enabling the patient to devise strategies to limit self-harming behaviour. Specially trained case managers offer individually focused and consistent care.

In addition, the Trust has devised Borderline Personality Disorder Guidelines with a multi-disciplinary focus, developed specific care plans for community and inpatient settings and provided nurse training in personality disorders, among other improvements.

Finally, it appears that an emerging theme of the findings of the Trust’s review is that proper care planning and risk management were not undertaken or implemented effectively.

The Mental Health Act Code of Practice is clear that mental health providers should have robust policies in place for implementing care plans based on the Care Programme Approach, which include a robust risk management plan, especially where someone poses a risk of self-harm. It appears the Trust has these policies in place but these were not implemented consistently during Ms Bushell’s care, nor were the complexities of Ms Bushell’s condition and associated risks fully considered. I am encouraged that the Trust accepts where its care fell short of expectations and is taking action to make improvements.

Thank you for bringing the circumstances of Ms Bushell’s death to our attention. I hope this information is useful.

JACKIE DOYLE-PRICE

Report sections

Investigation and inquest

On 14th October 2014 commenced an investigation into the death of Linsay BUSHELL, who was aged 37 when she died on the 13th October 2014. The investigation concluded at the end of the inquest on 24/25 April 2017 . The found that Linsay had died from: la Asphyxia Ib Compression of the neck Ic Ligature Strangulation The Jury Concluded that Linsay Bushell died as a result of an accident due to the unintended consequence of a deliberate act:

Circumstances of the death

Linsay Bushell was a 37 year old woman who detained under S 3 Mental Health Act 1984 from January 2014 at the Brunswick Ward of the Broadoak Unit: She had an extensive history Of self-harm. On the Evening of the 13th October 2014 she was found having self-ligatured under her bed in a 4 bedded dormitory. In spite of attempts at CPR she was certified as having died at 21.39 at the Royal Liverpool University Hospital the same day: She had suffered all her adult life a borderline emotionally unstable personality disorder for which psychological therapies had not been commissioned. Mersey Care NHS Foundation Trust has taken the initiative from lessons learnt from this tragic death to develop therapies to treat EUPD in both hospital and in the community in Merseyside and Lancashire.

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 to commission appropriate services

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Shared signals

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Report details

Reference: 2017-0137
Date of report: 25 April 2017
Coroner: Andre Rebello
Coroner area: Liverpool and Wirral

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Nov 2017 (estimated).

Sent to

Department for Health

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.