Magdalen Dwerryhouse

Coroner's concerns

AI summary

Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.

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1. During the inquest evidence was heard that: - The referral of the deceased to 5 Boroughs Partnership NHS Foundation Trust by on the 4th November 2013 was appropriate and gained an appropriate response from the Trust by the initial assessment on the 6th November 2013_ The initial assessment was arranged by contacting family telephone numbers given byE on the letter of referral to the Trust but the subsequent appointment on the 15t November 2013 was not made in the same way and did not involve the family as requested by ii When attended the premises on the 15* November 2013 and failed to gain access they made no contact with a member of the family, nortt and did not appear to take account of the information recorded on the initial referral letter submitted by They did not make contact with the Trust's office on that date and subsequently there was no contact with the family and no attempt to rearrange the appointment, other than the indication of a letter 11 days later which was not sent; Furthermore there was no contact with the family following the telephone call byl bn the 21s November 2013. her, the they jii, Greater Manchester Fire and Rescue Service provide home safety checks free of charge to persons at an increased risk of fire and the Fire Service has developed a register of individuals who are at a increased risk of fire. Had information regarding the deceased's condition been referred to the Fire Service she would have been included on this register and prioritised for home safety checks. The Fire Service continues to develop and utilise referral pathways with other agencies in form of partnership agreements to ensure that individuals at increased risk of fire are identified at the earliest opportunity and relevant fire prevention interventions are implemented: The Fire Service recommends that Clinical Commissioning Groups, Mental Health Trusts and other health providers develop agreements regarding the sharing and use of information that would enable the delivery of more cost effective support and potentially improve outcomes for those most at risk: The Greater Manchester Fire and Rescue Service has attempted over the last 2 years to develop a partnership with 5 Boroughs Partnership NHS Foundation Trust but evidence was given the Fire Service that attempts at a partnership had been thwarted and delayed and there appeared to be a lack of continuity of staff involved in discussions and a lack of motivation on the part of the Trust to enter into a partnership. The Fire Service identifies individuals with mental health and behavioural problems as vulnerable individuals at high risk and, whilst it has been difficult to form a partnership with 5 Boroughs Partnership NHS Foundation Trust; the Fire Service does have partnerships with other Mental Health Trusts within the area covered by the Greater Manchester Fire and Rescue Service. The Fire Service would have been prepared to attend the multi-disciplinary team meeting held at the 5 Boroughs Partnership NHS Foundation Trust on the 7th November 2013 to assist in assessment and any action to be taken in relation to the deceased but there was no contact with the Fire Service, who was not invited to attend_ I have concerns with regard to the following:- The systems and procedures within 5 Boroughs Partnership NHS Foundation Trust with regard to the arrangements of appointments with vulnerable individuals particularly when directions are given by a Health Professional, namely in the case of the deceased. I have further concerns with regard to procedures to be undertaken if a visit fails for lack of access including contact with family and the original referrer to rearrange an the by appointment as soon as possible: iii_ The absence of any partnership agreement between the Greater Manchester Fire Service and 5 Boroughs NHS Foundation Trust which has failed to develop over the last two years and which is essential to allow the Fire Service to take action to prevent future deaths:
3. I request you to consider the above concerns and to review following:- The arrangements of appointments, contact with members of the family and the procedures in relation to failed home visits with a view to immediate action to contact family members and original referrers to alert them to the failed visits and to establish the reason for failed visit and to rearrange the visit as soon as possible: ii The formation of a partnership with the Greater Manchester Fire and Rescue Service:

Responses

1 respondent

5 Borough Partnership NHS Trust NHS / Health Body

8 Jul 2014 PDF

Action Taken

The Trust has reviewed and amended operational guidance for community teams, specifically regarding actions when service users miss appointments. They have also established an information-sharing agreement and reciprocal training arrangements with the Greater Manchester Fire and Rescue Service. (AI summary)

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Dear Mr Walsh, Re: Magdalen Bernadette Dwerryhouse Deceased Thank you for your letter dated 30 May 2014 with regards to your findings into the death of Magdalen Dwerryhouse and the directions given under the Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013_ would like to advise you of the actions the Trust has taken both prior to the inquest and since receiving your letter. Taking your points in turn can confirm the Trust have completed the following: Arrangements for Appointments Contact with Family Members DNA We have implemented a full review of the operational guidance that all community teams work to: To address the areas of concern raised within our internal investigation and also by yourself; we have significantly amended the advice and guidance issued to our clinicians around what action to take if a service user does not attend an appointment, or is not at home when a planned appointment occurs As an interim measure before we are able to fully implement this new guidance across all community teams, the Assistant Director of Operations has instructed an immediate change in practice within all our Assessment Teams The changes are stated below If a visit to a service users does not occur, that telephone call to the referrer must occur within 24 hour of the visit to alert them of this fact If a service user has been referred to our service 3 times within months and repeatedly not attend appointments, or home visits, then a professionals meeting is to Chief Executive: Mr_Simon J Barber Chalman: Trust Headquarters, Hollins Park House _ Hollins Lane; Winwick, Warrington, WA2 8WA Mini Com Number 01925 684094 01548169

be called to review the service user's case for referral and potential need for assertive outreach in conjunction with the original referrer. In circumstances where a visit does not occur the practitioner should make use f the information provided at the point of referral in view of rearranging further appointment: This may include contact with family members. The impact of a failed visit should be considered in line with the overall case and appropriate actions taken and documented which may include rescheduling the failed appointment Formation of a Partnership with Greater Manchester Fire and Rescue Service Since Mrs Dwerryhouses death, significant work and progress has been made with Greater Manchester fire service in preparation for the final partnership agreement being signed We have completed an Information Sharing Agreement and this has been agreed in principle and will form part of the overall partnership agreement; To accompany the agreement;, operational protocols to assist staff with how to best utilise this partnership agreement have been drawn up and are also ready for introduction on completions of the partnership agreement. There was a further meeting between 5 Boroughs NHS Partnership foundations Trust and Greater Manchester Fire and Rescue Service on the 18h July to establish agreement for the principles set out in the partnership agreement; leading to formal signing in the near future: As part of this agreement; we will provide GMFRS with assistance if feel someone who has utilised their service may have a mental health concern, and reciprocally, our Trust consider a referral to the GMFRS if a fire safety assessment is considered appropriate_ This arrangement also provides reciprocal training arrangements for both organisations_ Similar processes are either in place or in draft with other Fire and Rescue services in other parts of our catchment area. This will be reviewed by an Executive Director and signed for on behalf of the organisation. If can be of any further assistance or you require further information about the steps we have taken, please do not hesitate to contact me

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Circumstances of the death

Magdalen Bernadette Dwerryhouse died at her home address) Bradley Lane, Standish, Wigan on the 25t November 2013. The deceased lived alone at 223 Bradlev ane, Standish, Wigan with the support of her daughter who lives in France and her Grandson Who llives nearby.
3. In July 2013 the deceased developed loss of appetite and weight which was investigated and in November 2013 she developed evidence of a paranoid mental illness which was being assessed at the time of her death
4. On the 1s November 201. who was the deceaseds General Practitioner , was contacted byem and she expressed concern about her Mother's mental state visited Artery the deceased on the same day and she saw the deceased in the presence of conducted an assessment which identified two issues namely auditory hallucinations and possible delusions. also recorded that there was no evidence of depression but there was a previous history of the deceased failing to answer telephone calls from her phone:
5. referred the deceased to 5 Boroughs Partnership NHS Foundation Trust for mental health assessment and the referral was received by the trust on the 4t November 2013.
6. On the 6th November 2013 who is a registered Psychiatric Nurse and a Senior Nurse Practitioner with 5 Boroughs Partnership NHS Foundation Trust; attended deceased's home address and conducted a mental health assessment; arranged the assessment withl who was present; to allow access to the premises and to assist with information in relation to the assessment. The mental health assessment was arranged with view of the fact that the referral form completed by land submitted to 5 Boroughs Partnership NHS Foundation Trust stated "Will not answer the telephone and gave contact telephone numbers for and Following the assessment the deceased was discussed at a multi-disciplinary team meeting at 5 Boroughs Partnership NHS Foundation Trust on the 7th November 2013 and the meeting decided that the deceased should be reviewed by an Occupational Therapist and a Consultant Psychiatrist: The review was arranged for the 15t November 2013 and the review was to take place at the deceased's home address: Notice of the review and the visit of the Occupational Therapist and Consultant Psychiatrist was sent to the deceased by letter and no arrangements were made by contacting eitherb lor in accordance with previous contact arrangements On the 15th November Consultant Psychiatrist and acting Deputy Manager for the Wigan and Leigh Mental Health Assessment Team, being part of the 5 Boroughs Partnership NHS Foundation Trust; visited the deceased's home address without any arrangement to meet at the address as before: The deceased did not respond to attempts to to the premises by and_ who left the premises without making telephone contact with either Or No contact was made with office of 5 Boroughs Partnership NHS Foundation Trust on the 15th November 2013 and there was no contact with who has made the initial referral to the Trust; A note was placed on the record of 5 Boroughs Partnership NHS Foundation Trust on the 18th November 2013, which noted the failed visit to the deceaseds home address, and on the 21st November 2013 telephoned the_Trust to_be_ the the gain entry any informed that the visit had failed and suggested contact with the family. No contact was made with the family and evidence was given at the inquest that a letter was to be sent to the deceased on the 26th November 2013 to rearrange the visit but the letter was not sent:
9. On the 25th November 2013 the deceased was found at her home address, which had been damaged by fire originating in the kitchen of the premises together with smoke damage arising from the fire: The deceased was found in a collapsed and unresponsive condition at the bottom of the stairs in the premises and she was diagnosed as having died at the premises on that date_
10. It was accepted at the inquest that the deceased was a vulnerable person but there had been no contact with any outside agencies including the Greater Manchester Fire and Rescue Service with regard to her vulnerability or to arrange further assessments to protect particularly in relation to fire:

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