Gillian Taylor

Coroner's concerns

AI summary

A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and negatively impacting patient engagement, thus increasing self-harm and suicide risk.

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In the 29" _ the Priory entry circumstances it is my statutory duty to report t0 you: (1) There is no acute facility in Powys for the treatment of acutely unwell patients_ which, the evidence showed, often leads to patients being moved the length and breadth of the country to an establishment where a bed can be found. The evidence also showed that the local acute unit at the Redwood Centre in Shrewsbury had recently experienced a significant reduction in the number of acute beds available compounding and exacerbating the problem: (2) As a consequence of above there is often a lack of continuity of treatment which can be to the detriment of the patient concerned_ (3) The evidence showed that; on balance, it is likely that the experience of being sectioned in these circumstances had an adverse effect upon Mrs Taylor which fuelled an unwillingness, on her part, to engage with Mental Health professionals thereby increasing her risk of self harm/suicide: (4) it is believed that Powys Health Board is the only Health Board in the country that has no facility available to it for the treatment of acute admission patients in the position of Mrs Taylor

Responses

3 respondents

Welsh Government Devolved Administration

5 Jul 2016 PDF

Action Taken

Following the report, Welsh Government facilitated a meeting between all Health Boards mental health managers to discuss using Welsh NHS beds whenever possible. They also highlighted the existing requirement for care coordinators and treatment plans for all patients in Wales receiving secondary mental health services, even when placed 'out of area'. (AI summary)

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Prif Swyddog Meddygol Dros Drol Acting Chief Medical Officer Grwp lechyd a Gwasanaethau Cymdeithasoll Health and Social Services Group NN) Llywodraeth Cymru Welsh Government erllc. Mr Andrew Barkley Coroner for South Wales Central Area Hleex dpan ^ # A_ t dyCn olke; 5 July 2016 Thank you for your bringing to our attention the regulation 28 report following the investigation into the death of Gillian Rose Taylor: have been sighted on Powys Teaching Health Boards response to address the concerns you have raised. Under the Mental Health (Wales) Measure 2010 (the Measure) all patients in Wales receiving secondary mental health services must have a care coordinator and a care and treatment plan: This applies to Welsh patients who are placed 'out of area'. It is the responsibility of 'home' health board to ensure the person receiving care and treatment has a care co coordinator and a holistic statutory plan. The care coordinator would normally attend reviews wherever a patient is, whether in England or Wales, this safeguard should assure continuity of care for all Welsh patients. It is for Powys which is a rural county to commission services for their smaller and dispersed population and in fact they do have acute mental health beds provided in Bronllys Hospital. There are also beds commissioned from neighbouring Trusts and Health Boards to minimise distances travelled by the population, or to provide expertise that require a level of critical mass and to meet professional guidelines that a population the size of Powys could not be expected to reach: Since your report a meeting between all Health Boards mental health mangers facilitated by Welsh Government has been held to discuss using Welsh NHS beds whenever possible if local beds are not available: It was accepted that proximity to a patients home would have to be considered in this context: hope you find this information helpful:

Powys Teaching Health Board NHS / Health Body

16 Jul 2016 PDF

Action Planned

Powys Teaching Health Board is working to repatriate Mental Health Services for direct delivery, expecting to treat more patients within Powys and reduce out-of-county placements. (AI summary)

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Dear Mr Barkley Re: Regulation 28: Report to Prevent Future Deaths Thank you for your letter of the 11 May 2016, received 18 May 2016, issuing Regulation 28 form in respect of the death of Gillian Rose Taylor: note the matters of concemn that you have identified through the course of the inquest and that, in your opinion, you felt there was a risk that future deaths would occur unless action was taken: In summary, having considered the matters you have raised, we have taken action as described belw to put in place robust, high quality, safe services for our Powys population: As you will read, these actions are continuing reflecting the current work within Powys Teaching Local Health Board to repatriate adult mental health services. In responding to the matters of concem that you have raised, have outlined below my responses to the four areas you have identified: There is no acute facility in Powys for the treatment of acutely unwell patients, which, the evidence showed, often leads to patients being moved the length and breadth of the country to an establishment where bed can be found: The evidence also showed that the Iocal acute unit at Redwood Centre in Shrewsbury had recently experienced significant reduction in the number of acute beds available compounding and exacerbating the problem: It is important to clarify that there is acute adult mental heath provision within Powys in addition to the services we commission from other providers close t0 our borders: RECEIVED 6 JUL 4u6 Dro / Your

Prior to the December 2015, four different health boards were responsible for the 48 adult mental health beds in Powys hospitals. These beds include the Felindre ward on the Bronllys Hospital which is an acute adult mental health unit. In addition Crisis Resolution Home Treatment Teams (CRHTT) are in place within Powys which provide evidence based hospital level care at home In North Powys, in addition to the services above, in-patient mental health services for Powys residents are also commissioned at Wrexham Maelor Hospital, Redwoods in Shrewsbury and independent sector hospitals. We also commission individual in patient beds at the independent hospital at Phoenix House which is geographically within As Powys is one of the most sparsely populated counties in England and Wales it is not possible to provide the full range of specialised in-patient services here. It is clear that PTHB would not be able to comply with all the requirements of the Royal College of Psychiatry needed to run some specialised services safely: In 2014 detailed work was undertaken with clinicians to work through some of the difficulties being experienced in North Powys, where services were being managed by Betsi Cadwaladr University Health Board. Montgomeryshire was found to have much higher levels of admission than would be expected for the population using national benchmarks for England and Wales: On a daily basis it was found that Montgomeryshire should have access to about 12 mental health beds for older people and about 12 for working age adults: At the time as the graphs show it was admitting about 35 patients. It must be emphasised that benchmarks are not a "cap" Or a "target" . Benchmarks just help show how the service compares to others across England and Wales. Admissions are based on assessment of clinical need. A series of steps was taken This involved establishing a fully functioning CRHTT which reduced the need for admissions out of county. Weekly discussions were put in place between Redwoods and local services to help get patients admitted to Redwoods when needed: Additional funding was allocated to the local service in Montgomeryshire, including for additional care co-ordination to help address out of county admissions. This was monitored on weekly basis. The graphs attached at Appendix 1 (enclosed) show that the difficulties with admission significantly reduced for a sustained period. the second graph indicates, acute admissions had been falling during October 2015 although started to rise during November: In the same period in South Powys there were vacancies on Clywedog Ward in Llandrindod Wells Hospital (run by Aneurin Bevan University Health Board (ABUHB)) which can admit older adults with functional mental illness. The management of adult mental health services in Montgomeryshire and Ystradgynlais has now transferred back to PTHB: It is hoped that the acute unit in South Powys will return to Powys management in the Autumn 2016. However this depends on securing permanent medical staff to fill vacant posts, the latter relating to to a recruitment issue and not a funding issue_ (2) As a consequence of 1 above there is often a lack of continuity of treatment which can be to the detriment of the patient concerned. site , Powys: As they

(3) The evidence showed that; on balance; it is likely that the experience of being sectioned in these circumstances had an adverse effect upon Mrs Taylor which fuelled an unwillingness, on her part; to engage with Mental Health professionals thereby increasing her risk of self harml suicide. As explained above additional funding was provided to strengthen care CO- ordination. A Crisis Resolution Home Treatment Team was also implemented providing acute hospital level care at home with which Mrs Taylor engaged: Mrs Taylor would have had statutory care co-ordinator and care and treatment plan under the Mental Health (Wales) Measure 2010. As set out in Paragraph 3.19 of the Code of Practice to Parts 2 and 3 of the Mental Health (Wales) Measure 2010 it is not necessary to change the care co-ordinator when a patient is admitted to hospital: We acknowledge that when a North Powys patient is admitted out of area this can be disruptive for both patient and their family, and prior to admission out of county we seek to explore every in county treatment option first: We continue to commission inpatient provision in the Redwoods centre , however across the UK access to specialist beds is limited and unfortunately we share the same challenges in securing in patient beds close to home as many of our neighbouring Health Boards. We regret that at the time of Mrs Taylors detention under the Mental Health Act that the nearest bed available to meet her needs was in Bristol, however detailed assessment of Mrs Taylor's mental health care needs determined that the safest care optnion was to detain her (under the Mental Health Act): At the time of her detention, had a suitable placement been available more locally, this would have been commissioned. Our work to repatriate Mental Health Service to direct delivery by Powys Teaching Health Board will directly improve our ability to admit and treat more patients within Powys, and it is our expectation that in future significantly fewer Powys residents will be treated out of county for their mental health care needs. (4) It is believed that Powys Health Board is the only Health Board in the country that has no facility available to it for the treatment of acute admission patients in the position of Mrs Taylor: have answered Question 4 above as part of Question 1. To aid your further understanding of this information have provided the graphs with regard to admission and summary of mental health services in Powys (Attachment 1): hope this information provides you assurance that we are working towards appropriate pathways of care for Powys residents requiring mental health care. We wish to formally offer our sincere condolences to Mrs Taylors family and we continue to repeat our offers of support to her family as they continue to adjust to life without her: key

If you have any further questions, please do not hesitate to contact me_

Kent and Medway NHS Trust NHS / Health Body

PDF

Action Taken

Kent and Medway NHS Trust revised its 'Unable to Contact' Protocol, launched it at the Acute Leadership Forum, and cascaded training to CRHT teams. The new Protocol is being piloted in CRHTs trust wide for 3 months to ensure the changes are robust and workable. (AI summary)

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Dear Mr. Morris, Julie Margaret Rose deceased Regulation 28 Prevention of Future Deaths Report refer to your letter of 14 December 2015 enclosing the Prevention of Future Deaths Report; arising out of the inquest into the Death of Julie Margaret Rose, which was received by my office on 22 December 2015. am most grateful for you bringing these matters to my attention; am also very grateful for you having agreed to an extension for the Trust providing its response as it now means that am able to confirm what action has been taken_ In your letter you set out the following concerns, which will deal with in turn: Although the Trust's Unable to make Contact Protocol ("the Protocol") had been reviewed since Miss Rose'$ death; am concerned that it is insufficiently clear as to when the Crisis Resolution Home Treatment Team members should request a police welfare check in respect of patients who have been identified as 'Red' for the purposes of the Trust's R A G rating system: In particular, am concerned the Protocol does not specifically stipulate circumstances where a request for a welfare check is mandatory (for example; after a certain period of time has elapsed since contact was last; andlor after a certain number of attempts at contact andl or after attempts at telephone contact and a home visit have been unsuccessful: am aware that at the inquest you heard evidence from Acting Assistant Director for East Kent Acute Mental Health Services about the considerable efforts the Trust had begun implementing to mitigate the risk of similar deaths occurring: Following the inquest; the Trust continued in this work in addition to taking further steps, in particular, making changes to the Unable to Make Contact' Protocol. The Protocol has been subject to a further Chairman - Andrew Ling Chief Executive Angela McNab Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone_ Kent ME16 9PH Tel: 01622 724100 Fax: 01622 724165

review and amended. enclose a copy of the new Protocol which is now in use and which is subject to a three month pilot: You will note that that the new Protocol gives clear guidance to staff, setting out details of the steps that must take when a service user has missed planned contactIcall with the Crisis Resolution Home Treatment Team (CRHT) , starting from those required within the initial hour The protocol highlights the importance of involving family members, friends, carers and other professionals where a concern is raised to try to make contact and to gain collateral information: iv) The next step is for a risk assessment to be reviewed and a plan of next steps agreed. Where following these initial steps (including contacting family) has occurred but have still been unable to make contact, the Protocol requires that the team make a home visit and take the risk assessment with them; The protocol is clear that if no contact is made then staff must attend the home address as soon as clinically indicated and that staff should prioritise workloads accordingly, based on risk assessment and taking with them a hard copy of the most recent risk assessment: Staff may want to try to arrange to meet a carer or next of kin at the address that may have been previously agreed, as a means of accessing the address If, after attendance at the service users home, still cannot be reached, have the option of asking the Police for support: Staff need t0 do that via a 999 call where the risk indicates the need for this, and wait for police at the_scene with the risk assessment hard copy to share with them vii) The new Protocol needs to be read in conjunction with the recently finalised 'Acute Service Line Welfare Check Protocol' which is a document that has been jointly developed with Kent police. A copy of this is enclosed for ease of reference. The 'Welfare Check Protocol' is applicable to in-patient's and people under the care of the Crisis Resolution Home Treatment team viii) The priority and focus is that the right people with the right information will take urgent steps to reach the service user. This may or may not be with the assistance of the police and there is an expectation by the police that we as a Trust have taken all necessary steps to make contact first: ix) The 'Welfare Check Protocol' describes how Police will carry out a 'welfare check' when a request is made to police about an individual; if it is an emergency and there is a real concern that something serious is about to, or has already, occurred to the relevant individual on those premises The police will respond because it enables a professional intervention if an individual is in need of immediate assistance due to a health condition, injury or some other life threatening situation. Unless this threshold is reached, police have no duty, and therefore no power; to take any action once outside those premises. Xi) This is why the Trust 'Welfare Check Protocol' now focuses on the up to date information on risk, being available to those who attend properties in an attempt to establish contact_ Chaiman Andrew Ling Chief Executive Angela McNab Trust Headquarters Farm Villa, Hermilage Lane, Maidstone, Kent , ME16 9PH Tel: 01622 724100 Fax: 01622 724165 they they they will they

2 In the course of the hearing, heard evidence that the Protocol has been 'reinforced' across the Crisis Resolution Home Treatment Team: Notwithstanding this, a shift coordinator who gave evidence was clearly not conversant with the Protocol, raising questions as to the adequacy of the steps taken by the Trust to date in this respect: Louise Clack; who was the senior member of Trust management at the inquest has briefed about the evidence given by the shift coordinator: The lack of conversance with the policy was disappointing: An immediate action from this was taken to ensure that the contents of the policy are highlighted to staff in shift handovers and team meetings, and where necessary, for this to be dealt with during individual supervision. There have also been recent changes in the structure of the Crisis Resolution Home Treatment teams, meaning that there is an experienced practitioner in the form of a clinical manager who are on shift for extended hours, including up to midnight and at weekends, that operational staff in the CRHT can seek advice from: This is in addition to the On Call Manager and Consultant rotas that were already in place_ iii) The new 'Unable to Make Contact' Protocol was launched at the Acute Leadership Forum, with training given on 8 March 2016, cascaded to all CRHT teams. This has also been circulated to all matrons and managers and training is being provided at minuted team meetings_ It has also been highlighted in the Acute Service Line Lessons Bulletin. The same process was used to launch the Acute Service Line Welfare Check, which has been effective. iv) The new Protocol is being piloted in CRHTs trust wide for 3 months to help the teams to understand what changes may need to be made; in order to make this robust and workable process_ AIl CRHT staff have been asked to provide details to their manager each time the protocol is used during the pilot period with details of how it worked and of the outcome of events so that these can be audited. The outcome of this monitoring will be collated in mid June and will then report back into Patient Safety. The auditing process will also help ensure consistency of use and help us identify if there are any issues relating to the understanding of application of the Protocol with certain staff so that this can be picked up in supervision: vi) The results of the audit of this pilot can also be fed into the overarching policy that we are currently finalising with the Kent Police to cover all of the Trusts working with them and to ensure a consistent approach based on the identified risk with that employed by the community teams Chairman - Andrew Ling Chief Executive - Angela McNab Trust Headquarters Farm Villa, Hermilage Lane_ Maidstone, Kent ME16 9PH Tel: 01622 724100 Fax: 01622 724165

that the above shows that the Trust does take very seriously the matters that have been raised in the PFD report and that we are continuing to work hard to deal with these issues

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Investigation and inquest

On the 7lh January 2016 commenced an investigation into the death of Gillian Rose Taylor concluding at the end of an inquest on the April 2016. The conclusion of the inquest was "Suicide" and the cause of death of death was Ia. Hanging

Circumstances of the death

The deceased had a lengthy history of mental health issues attempting her first suicide, the evidence showed, at the age of 16. She had attempted suicide on a number of occasions in the past She suffered a significant relapse in her mental health around August 2015 and had intensive input from the Mental Health Team being dealt with and or contacted on an almost daily basis. On the 31* October 2015 she was detained under Section 2 of the Mental Health Act after it became clear that the input that she was having was not working and there were real concerns for her mental health and her risk of self harmlsuicide As no acute beds were available for her within Powys area or indeed any surrounding area she was taken in the early hours of the morning to Bristol Hospital where she remained until the Section was lifted on the 16 November: In the intervening period she had become physically unwell and was moved to another hospital for main stream medical care Upon discharge home she remained under the care of the local community Mental Health Team (Crisis Resolution Home Treatment Team) until her death on the 3r January 2016. On that day concern was raised by her daughter who was unable to contact her and when police forced at her home address she was discovered hanging from a ligature on a bedroom door at her address

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:

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