Source · Prevention of Future Deaths

Henry Marsh

Ref: 2014-0306 Date: 2 Jul 2014 Coroner: Andrew Walker Area: London (North) Responses identified: 1 / 1 View PDF

The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.

Date 2 Jul 2014
56-day deadline 27 Aug 2014 est.
Responses identified 1 of 1
Community health care and emergency services related deaths

Coroner's concerns

AI summary
The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.
View full coroner's concerns
_ The numbers of patients that the Home Treatment Team have under their care were too many and there were difficulties in holding effective multi_disciplinary meetings when

Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent;, Barnet; Haringey and Enfield) carrying such a large caseload

Responses

1 respondent
Department of Health Central Government
PDF
Noted

The Department of Health acknowledges the concerns about the Home Treatment Team's caseload and refers the Coroner to existing national guidance and resources for Crisis Home Treatment Teams. NHS England intends to map this best practice guidance on to the mental health intelligence network, but there is currently no set timeline. (AI summary)

View full response
From Rt Hon Norman Lamb MP Minister of State for Care and Support Department Department of Health of Health Richmond House 79 Whitehall London SWIA 2NA Andrew Walker HM Coroner for the Northern District of Greater London North London Coroner's Court 29 Wood Street Barnet ENS 4BE Ve UaMes Thank you for your letter to Jeremy Hunt about the death of Mr Henry Marsh. am responding on his behalf as the Minister responsible for mental health policy: Your report detailed Mr Marsh's multiple diagnoses which included depression, a personality disorder, substance misuse issues, Post Traumatic Stress Disorder and alcohol dependence. The inquest concluded that Mr Marsh committed suicide whilst under the care of the local Home Treatment Team You are concerned that the team could not function effectively with its current caseload_ Home Treatment Teams are commissioned by local Clinical Commissioning Groups (CCGs) and resourcing these teams is therefore a matter for the local CCG. There is, at national level, very clear evidence base about the optimal effective composition and functioning of Crisis Home Treatment Teams (CHHTs) and this includes the following: The National Service Framework crisis home treatment policy: The University College London Child Outcomes Research Consortium National Institute for Health Research programme that advises on effective care models for CHTTs and online learning and three courses for those commissioning, establishing and implementing CHTTs. The Royal College of Psychiatrists College Centre for Quality Improvement, Royal College peer accreditation quality network that has robust evidence based standards against which teams can be judged: The National Audit Office report on CHTT optimal operational functioning: day

Department of Health The North East Strategic Clinical Network's published standards for crisis care pathways including CHTTs performance indicators from Monitor and the Care Quality Commission on metrics which CHTTs need to provide to ensure effectiveness: NHS England intends to map this best practice guidance on to the mental health intelligence network in the next phase of its programme of work. There is currently no set timeline for this to take place. In the meantime, NHS England has summary of the guidance with relevant links on the Health and Wellbeing website: http Ilbit lyLIrQNZUZ hope that this information is useful and thank you for bringing the circumstances of Mr Marsh's death to our attention_ ~neRs NORMAN LAMB Key - put

Report sections

Investigation and inquest
On the 25"h June 2012 opened an inquest touching the death of Henry Marsh years old. The inquest concluded on the 10"h June 2014 The conclusion of the inquest was "Suicide" , the medical case of death was Ia Polydrug Intoxication
Circumstances of the death
Henry Marsh had multiple diagnoses including Emotionally Unstable Personality Disorder Depression, Post Traumatic Stress Disorder; Alcohol Dependence and Poly Substance Abuse _ Mr Marsh was under the care of the Home Treatment Team at the time of his death: On the 18"h July 2012 Mr Marsh failed to attend his appointment with his psychologist who raised concerns with' Mr Marsh's father who found Mr Marsh unresponsive on his bed at his home_
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.

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2014-0306
Date of report
2 July 2014
Coroner
Andrew Walker
Coroner area
London (North)

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Aug 2014 (estimated).

Sent to

Department of Health and Social Care

Source links