Source · Prevention of Future Deaths

Michael Valentine

Ref: 2016-0032 Date: 2 Feb 2016 Coroner: Andrew Cox Area: Plymouth, Torbay and South Devon 2 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner raised concerns that an urgent mental health act assessment application was rejected without the GP being notified, and urgent rejections were not clearly marked or accompanied by a phone call to the doctor.

Date 2 Feb 2016

56-day deadline 29 Mar 2016 stated in the report

Responses identified 2 of 2

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The coroner raised concerns that an urgent mental health act assessment application was rejected without the GP being notified, and urgent rejections were not clearly marked or accompanied by a phone call to the doctor.

View full coroner's concerns

_ (1) The circumstances in which an urgent application for a mental health act assessment was rejected and yet did not come to the attention of the relevant GP. have written separately to the Senior Partner at the Practice bringing administrative shortcomings at the Surgery to his attention. At Inquest; however, it was accepted by) that where urgent applications for assessment are received these should be marked as urgent where are rejected. This did not happen. Additionally, it was felt that a telephone call should accompany the rejection to ensure the doctor is aware that the application has been rejected and the reasons for that decision.

Responses

2 respondents

Michael Valentine

Indexed date: 3 Feb 2016 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The practice conducted an audit of post on 23 February 2016. • A re-audit was undertaken on 22 March 2016. • The practice met with secondary care psychiatry colleagues to discuss the rejection process and conducted a Significant Event Analysis.

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Dear Mr ( OX Ref:_Regulation 28 report to Prevent Future Deaths: Patient: Mr_Michael John_Valentine dob: 26.03.69 dod:_16.09.154 Thank Yo ! for your letter dated 3rd February 2016 addressed to Dr Hall. Dr Hall has passed your correspondence to me as the person best suited in the Practice to arrange the actions to be taken. An audit of post was taken on 23/2/16. 235 pieces of correspondence were referred on this 216 were distributed to the GPs working that GP does not routinely work that day and 19 pieces of correspondence were reviewed by the Doctor for urgency and 18 pieces of correspondence were deemed safe to leave for the doctors return one later A re-audi: was undertaken on 22/3/16. 209 pieces of correspondence were received 0n this 175 were Jistributed to the GPs working that 2 GPs were not working that 100% (34) of their correspondence was reviewed by the Duty Doctor for safety and 33 pieces of correspondence were deemed safe to wait for the GPs to return to review. On balance we are happy that we now have robust procedures for reviewing post and electronic communication within the Practice t0 our patients safe We met Iith our Secon Care Psychiatry colleagues on 18h March 2016 and discussed the rejection , rocess as well as carrying out a Significant Event analysis on Mr Valentine'$ death. enclose copy of the minutes and outcomes of that meeting:

Michael Valentine Response2

Indexed date: 21 Mar 2016 PDF

AI-classified response stance Action Planned

AI-generated response summary

• Staff rejecting urgent referrals will contact the referrer directly to confirm the outcome of their assessment. • Advice will be sought from the Local Medical Committee regarding how learning can be shared between primary and secondary care.

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Dear Sir am writing in response to your letter sent to our Medical Director In order to progress this we have had meeting with Senior Management of Livewell South West and myself as Clinical Director of Adult Mental Health and have reviewed the case have reviewed the process of urgent referrals: We note that Knowle House Surgery considered this as part of their Significant Event Process and we met with the practice on Friday 18h March. We understand that the practice will forward a record of the meeting to you. Our actions are as follow: In future any staff that reject an urgent referral will be contacting the referrer direct to confirm the outcome of their assessment of the referral, 2 We will also continue with our usual practice that Devon Referral Support Services (DRSS) will notify the referrer; in writing; of any referrals not accepted. 3 We will be seeking advice from the Local Medical Committee to ask how learning can be shared throughout the Primary Care arena and Secondary Care arena. On a matter of accuracy, the request for an assessment from the North Community Mental Health Team was a request for a Mental Health assessment, not a Mental Health Act assessment; which would be a different process With all best wishes

Report sections

Investigation and inquest

On 21 September 2015 commenced an investigation into the death of Michael John Valentine, 46 years of age. The investigation concluded at the end of an inquest on 2 February 2016. medical cause of death was recorded as (a) Helium Toxicity and the conclusion was that Mr Valentine had committed Suicide

Circumstances of the death

On 17 August 2015 Mr and_ (separated: In the early hours of 18 August Mr Valentine posted on line an image of a self-inflicted wound: The Police were notified. Mr Valentine was taken to a place of safety at Derriford Hospital pursuant to Section 136 of the Mental Health Act, He underwent a formal assessment and although distressed and upset was felt not to be suffering from a mental disorder: He was discharged without follow up. On 20 August Mr Valentine was seen by one of the GP's at your Practice She did not then feel that he was actively suicidal nor did she feel it was necessary to refer him to the mental health team: On 27 August] (spoke again with Mr Valentine who disclosed to her that he was not eating: On 2 September vour surgery received a letter from Mr Valentine indicating thatthe_was on hunger strike spoke to him; She also spoke to her colleagues and Consultant Psychiatrist: Submitted an urgent referral for a mental health assessment: To her knowledge at the time this was not responded to. On 10 September (spoke to Mr Valentine again. At that point he told her that he had not eaten for 25 days On 14 September Mr Valentine spoke to one of colleagues: On 16 September Mr Valentine was found deceased 3 The Crescent; Plymouth, PLI 3AB Tel 01752 204 636 Fax 01752 313297 The

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you as Senior Partner of Knowle House Surgery have the power to take such action. While it is a matter for you to reflect upon you may feel that it would be of benefit to audit post that now received routinely into the Surgery: How long is it before this is reviewed by a doctor? Additionally, you may feel there would be some benefit in arranging a meeting with your colleagues in Secondary Care to discuss the procedure for rejecting urgent mental health act assessments_ have written_in similar terms to the Medical Director at Plymouth Community Health Care. At the Inquest indicated that she felt this would be an appropriate step to take: Finally, you may feel that it would be sensible to re-consider the circumstances of Mr Valentine's death in light of the clinical decisions following the telephone contact on 10 September at a significant event meeting: would be grateful if you would send to me a record of that discussion if you believe it appropriate to hold one

Similar PFD reports

Shared signals

Report details

Reference: 2016-0032
Date of report: 2 February 2016
Coroner: Andrew Cox
Coroner area: Plymouth, Torbay and South Devon

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Mar 2016 (stated in the report).

Sent to

Knowle House Surgery

Livewell South West, Mount Gould Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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