Source · Prevention of Future Deaths

Mariana Pinto

Ref: 2017-0093 Date: 14 Mar 2017 Coroner: ME Hassell Area: London Inner (North) Responses identified: 2 / 1 View PDF

The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not escalate an urgent situation or prompt emergency services involvement.

Date 14 Mar 2017

56-day deadline 31 May 2017 est.

Responses identified 2 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. It seemed to me at inquest that, when Ms Pinto left the emergency department the day before her death, the limitations of the crisis team were not made clear to her family and friends.

2. The view of the psychiatrists treating Ms Pinto in the emergency department was that she was suffering cannabis withdrawal, which I heard is generally at its worst during the first three days.

Her symptoms were now quiescent, but it would have been very helpful for her family to know that, most particularly as she had taken cannabis the night before, once the lorazepam wore off she might well have a resurgence of symptoms though these were not expected to be as severe as they had been. Worsening advice could then have been delivered in this context, with a clear plan of action.

It is a theme I have noticed in deaths such as Ms Pinto’s, that clinicians’ expectations of illness progression are not necessarily communicated effectively to families, to enable families to identify unexpected deterioration and then to act swiftly and appropriately.

3. The band 7 mental health nurse who took the call to the crisis line at 3.32pm on 16 October, did not suggest to Ms Pinto’s husband that call the emergency services while the nurse rang Ms Pinto and spoke to her to offer what support he could.

When told him that the situation was now urgent, the nurse responded that the time for home visits was 5-7pm. After the call had ended, the nurse did not discuss with colleagues the potential to bring the home visit forward.

The nurse did not ring the emergency services himself in case had been unable to make the call.

Responses

2 respondents

East London NHS Trust NHS / Health Body

PDF

Action Taken

Following a serious incident review, the Trust updated its Operational Policy for CMHT, mandating that opt-in letters be sent within 5 working days, and will conduct local audits to ensure compliance. (AI summary)

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Dear Sir Inquest touching upon the death of Luke Moulding This is a formal response to your Regulations 28 Report dated 13" April in which you set out your concerns relating to the care Mr Moulding received East London NHS Foundation Trust, Your concerns related specifically to a in sending Mr Moulding an 'opt-in' letter following his last appointment with a psychiatrist at the Community Mental Health Team (CMHT) on 11*h November 2016_ understand that you were assisted at the Inquest by statements from staff involved in Mr Moulding's care. psychiatrist who saw Mr Moulding on 11"h November highlighted in her statement that Mr Moulding had left his appointment stating that he did not wish to engage with the CMHT. Following this appointment the psychiatrist had decided that Mr Moulding should be sent an opt-in' letter setting out that he still had the option to call the CMHT for an appointment if he wished, The psychiatrist set out that opt-in letters are normally typed and sent within 10 working days However, this had not been sent at the time of Mr Moulding's death: Itappears that your concern is around the timing of such & letter and you suggest that a pre-printed letter could be sent providing sufficient information, thereby cutting down on any delay incurred by waiting for the letter to be typed. Chief Executive: Dr Navina Evans Ian from delay The

Following Mr Moulding's untimely death the Trust undertook & Serious Incident Review: This review identified the delay in sending Mr Moulding an opt-in letter as & care delivery problem. The reviewers identified that the Operational Policy for CMHT did not provide guidelines on the service timescales for providing opt-in letters and were concerned to find that the lead time in November 2018 was up to 30 days_ It was therefore recommended that the Operational Policy be updated to provide appropriate tirescales Action was subsequently undertaken to the Operational Policy which now requires that opt-in letters should be sent within 5 working days_ Compliance against this timescale will be the subject of Iocal audit to ensure compliance_ Whilst a pre-printed letter was not thought to be suitable , hope that the action taken provides you with assurance that the Trust has taken appropriate action and that your concerns have been adequately addressed. If you do require further information please do not hesitate to contact me_

response Pinto

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Action Planned

East London NHS Foundation Trust is developing a written discharge care plan to clarify the limitations of the Home Treatment Team, and will increase flexibility to bring forward visits for service users experiencing deterioration in their mental health between scheduled visits from October 2017. From October 2017, the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service. (AI summary)

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Dear Madam Inquest touching upon the death of Mariana Pinto This is a formal response to your Regulations 28 Report dated 4th March in which you set out your concerns relating to the care Ms Pinto received from East London NHS Foundation Trust. Your concerns related to the following three points: Limitations of the crisis team were not made clear to Ms Pinto's family and friends Provision of information regarding a possible resurgence of symptoms as a result of cannabis withdrawal and advice on a clear plan of action. The handling of the phone call to the crisis line made by Ms Pinto's husband at 3.32pm on 16 October. will address each of your concerns in turn below: am aware that you heard evidence during the course of the Inquest that following psychiatric assessment in A&E Ms Pinto had been referred to the Home Treatment Team (HTT) Chair: Marie Gabriel Chief Executive: Dr Navina Evans 22nd May

You were informed by witnesses that the HTT does not provide an emergency service and in the event that emergency assistance is required assistance the individual should attend A&E with assistance sought from Police or Ambulance services when required: acknowledge that although the family were provided with crisis information on discharge they were not clear about the limitations of the HTT in relation to providing an emergency response. It is obviously important to ensure that both the patient and relativeslcarers are aware of the steps to take should there be a serious deterioration in an individual's mental state. Having considered your concern am confident that this will be addressed by the formulation of a written discharge care plan which is currently being developed and will in future be provided to all service userslrelatives prior to discharge from A&E following a psychiatric assessment. This care plan will set out who the service user was seen by, what the follow up plan is, contact details for relevant services and when an individual should expect to be contacted, Advice on when to seek urgent help and what to do in the event of an emergency will be included in this care plan, which will also deal with the concerns you have raised in relation to advice about resurgence of symptoms, what to look out for and what action to take in response. acknowledge that attending A&E and undergoing a psychiatric assessment can be a stressful and confusing experience for an individual and their relatives consider that the provision of a written discharge care plan will prove to be a useful tool. A template for this care plan has been drafted and will be presented at the Hackney Service User Focus Group at the end of this month_ Following consultation with service users and carers this will be implemented. am informed that Ms Pinto's mother-in-law will be providing views as a carer representative as of the consultation process. In relation to your final point regarding the handling of the call made by Mr Parra- Braun on the afternoon of 16th October it is important to confirm that in an emergency situation advice t0 contact Police and Ambulance is an appropriate and robust response. believe that your specific concern related to what support the HTT could have provided in the interim, for example the member of staff attempting to speak to the service user to deescalate the situation andlor personally contacting the emergency services_ Direct contact with the emergency services by mental health staff is not straight forward where family or friends are in attendance at the scene, as Police and Ambulance services require as much information as possible in relation to access and a description of the current situation from relatives or carers. However, in the event that a service user is on their own at a time of crisis then staff could intervene to call an ambulance or request that the Police attend to conduct a welfare check Advice on de-escalation of a crisis is a role that is fulfilled by the HTT. This can be in the form of advice at the time of a call to the crisis line or a return call following the advice to contact the emergency services_ It is the standard practice of the team to follow up on calls to the emergency services either by telephone or in person. Whether to speak to a service user directly whilst their relative contacts emergency services need to be carefully considered on a case by case basis. Chair: Marie Gabriel Chief Executive: Dr Navina Evans part

understand that you heard evidence during the course of the Inquest that additional funding had been secured for the HTT and from October 2017 the team will have increased flexibility to bring forward visits to those service users who experience a deterioration in their mental health between scheduled visits. From October 2017 the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service The City and Hackney Home Treatment Team had previously operated one shift only each day of the weekend, with a morning shift on a Saturday and an evening on Sunday: This has since been changed to providing both a morning and an evening shift to improve provision of visits on the weekend, With the changes already undertaken and those planned for implementation over the coming months hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns. If you do require any further information please do not hesitate to contact me

Report sections

Investigation and inquest

On 19 October 2016, I commenced an investigation into the death of Mariana Hungria Bayam Veiga Pinto. The investigation concluded at the end of the inquest on 13 March 2017. I made a narrative determination at inquest, which I attach. I recorded the medical cause of death as:

1a multiple injuries including ruptured left kidney.

Circumstances of the death

Mariana Pinto jumped from the third floor balcony of her home as a deliberate act, but without a proper understanding of what she was doing. She had attended the emergency department of the Homerton University Hospital the day before and had been assessed as not detainable under the Mental Health Act.

On the day of her death, her husband called the City and Hackney Crisis Line at lunch time and was told that she would receive a home visit between 5 and 7pm. He then called back at 3.32pm, explaining that his wife was deteriorating rapidly and needed to see someone urgently.

Half an hour later, Mariana Pinto jumped.

Copies sent to

Care Quality Commission for England, psychiatrist, City & Hackney, emergency physician, Homerton Hospital, crisis team member, crisis team member

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0093
Date of report: 14 March 2017
Coroner: ME Hassell
Coroner area: London Inner (North)

Responses identified

Responses identified 2 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 May 2017 (estimated).

Sent to

East London NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.