Source · Prevention of Future Deaths

Roshan Abbas Ladak-Ebrahim

Ref: 2013-0278 Date: 5 Nov 2013 Coroner: Andrew Walker Area: London (North) Responses identified: 1 / 1 View PDF

Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication contributed to safety concerns.

Date 5 Nov 2013

56-day deadline 31 Dec 2013 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

View full coroner's concerns

the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken: : Consideration to be given to issuing guidance when assessing risk of self-harm: The suggestion at the inquest was to firstly assess and record whether there is an immediate risk of self-harm. If there is no immediate risk of self-harm then the assessment should focus on whether there are any thoughts of self-harm, (recording frequency, duration, intensity etc) Whether there is a plan, (recording the details of the plan or plans, etc) and whether there is an intention to end life. Whether the individual is vulnerable to acting on impulse and any past history. The use of high, medium and low risk were considered unhelpful when assessing risk of self-harm_ Consideration to be given to giving guidance to health care professionals on the steps that should be taken to ensure that a patient is kept safe by those looking after the patient: In particular informing those looking after a patient that the patient should not be left alone where there is a concern that the patient is at risk of harming themselves Evidence heard at the inquest suggested that there was some confusion over whether this advice would breach a patients confidentiality. Consideration to be given to guidance whereby a doctor working in the community mental health agencies is required to have a consultation with a patient before prescribing medication that carries an increased risk of self-harm when first prescribed and arranges to see the patient again to assess the effect of the medication_

Responses

1 respondent

Department of Health Central Government

3 Jan 2016 PDF

Noted

The Department of Health acknowledges concerns about assessing self-harm risk and providing safety advice, referencing existing government action plans, NICE guidance, and GMC guidance on confidentiality and information sharing. (AI summary)

View full response

From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London SWLA 2NS' POC1 820980 Tel: 020 7210 3000 Mr A Walker Mb-sofs@dhgsigov.uk Senior Coroner North London Coroners Court 29 Wood Street Barnet ENS 4BE 2 3 JAN 2016 J ~_ Ucll Thank you for your letter following the inquest into the death of Roshen Abbas Ladak-Ebrahim. In your report you conclude that the medical cause of death was hanging; The deceased had been at home with his mother and hanged himself at his home on the evening of 11 October 2012. You explain that Mr Ladak-Ebrahim had been in contact with a number ofhealth care professionals and had his mother been told he was at immediate risk of self -harm she would have ensured that he was not left alone_ You raise the following concerns and ask that we give consideration to: i) issuing guidance when assessing risk of self-harm which looks at whether there is an immediate risk of self-harm Or intention to end life. ii) giving advice to health care professionals on steps to be taken to ensure a patient is kept safe by those looking after the patient. Evidence heard at the inquest suggested there was some confusion over whether this advice would breach a patient'$ confidentiality. iii) issuing guidance to doctors working in community mental health about the need for a consultation with a patient before prescribing medication that carries an increased risk of self-harm and a follow-up consultation to assess the effect of the medication; living

The Government has made a clear commitment in the Health and Social Care Act 2012 to give mental health equal priority with physical health This commitment is at the heart of Closing the Gap: Priorities for essential change in mental health; the Government'$ action plan for mental health which was launched by Nick on 2Oth January 2014. This sets out twenty five areas where people can expect to see and experience the fastest changes. This document bridges the gap between our longer-term ambition and shorter term action; It sets out our expectations and shows how changes in local service planning and delivery will make a difference in the next two O three years to the lives of people with mental health. Taking your points in turn: guidance on risk assessment is included in clinical guidelines (CG133 Self-harm: longer-term management) produced by the National Institute for Health and Clinical Excellence (NICE), and issued in November 2011, It is worth quoting a relevant extract; The guidelines state: A risk assessment is a detailed clinical assessment that includes the evaluation of a wide range of biological, social and psychological factors that are relevant to the individual and, in the judgement of the healthcare professional conducting the assessment, relevant to future risks; including suicide and self-harm. Risk assessment tools and scales are usually checklists that can be completed and scored by a clinician, or sometimes the service user, depending on the nature of the tool or scale They are designed to give a crude indication of the level ofrisk (for example, high o1 low) ofa particular outcome, most often suicide. The strong advice is, however; that cannot be used to predict future suicide O1 repetition of self-harm; Turning to confidentiality, there are clearly times when health care professionals, in dealing with a person at risk of suicide, may need to inform the family about aspects of risk to help keep the patient safe. I agree it is crucial that we address any confusion about how information can be shared That is why the Department of Health is already working with Royal Colleges and professional organisations to agree a consensus statement designed to promote greater sharing of information with the aim of preventing suicide, within the context of the relevant law_ We published this on 17 January at: gov uklgovernment/uploads/system /uploadslattachment_data/file/2742 92/Consensus_statement on information_sharing pdf Relevant guidance already exists on justifications for breaching patient confidentiality: The General Medical Council's Guidance to Doctors on Clegg they https / Iwww

Department of Health Confidentiality covers disclosures in the public interest and disclosing personal information without consent and specifically states: "Disclosure in the public interest may be justified when: failure to disclose information may put the patient, or someone else, at risk of death or serious harm, Or' (b) disclosure is likely to help in the prevention, detection or prosecution of a serious crime. In addition, the Department of Health published supplementary guidance to the NHS Confidentiality Code of Practice (November 2010, Ref 13912) on disclosing confidential information when there is a interest justification to do s0 and makes clear to healthcare professionals when it is appropriate to disclose personal information_ Finally, in relation to your suggestion of issuing guidance to doctors about prescribing medication to mental health patients that carries an increased risk of self-harm; there is currently comprehensive guidance on prescribing produced by a number of bodies including NICE; the General Medical Council and the British Medical Association. The guidance available specifically addresses how to assess the risk of prescribing a particular medication for individuals at risk of self-harm. Guidance often includes advice directed to patients and carers You mention that a medication that carried an increased risk of self-harm was involved in this case, but the name is not given. If you could supply this information we might be able to provide further advice about this aspect of the case. [ hope that this response is helpful and I am grateful to you for bringing the circumstances 0f Mr Ladak-Ebrahim'$ death to my attention. k~ Au JEREMY HUNT public

Report sections

Investigation and inquest

On 15th of October 2012 commenced an investigation into the death of Roshen Abbas Ladak-Ebrahim aged 22 years old. The investigation concluded at the end of the inquest on the 1st of November 2013 concluding on the 4th of November 2013_ The conclusion of the inquest was a narrative conclusion; the medical cause of death was hanging: Narrative conclusion: - On the 6"h September 2012 Roshen Abbas Ladak-Ebrahim was referred by the walk in centre to Barnet Primary Health Care Trust who forwarded the urgent referral to the Brent Assessment and Brief Treatment Team_ On the 11th September 2012 a nurse contacted Mr Ladak-Ebrahim and an appointment was made for an assessment on the 20"h September 2012 the nurse who spoke to Mr Ladak-Ebrahim had spoken to his mother on the 10th September 2012 and was told Mr Ladak-Ebrahim's history including the episode of self-harm and raised her concerns. On the 20"h September 2012 Mr Ladak-Ebrahim was taken by his father for his assessment Mr Ladak-Ebrahim was prescribed medication by a doctor following a multi-disciplinary meeting after Mr Ladak-Ebrahim was assessed by the nurse: Mr Ladak-Ebrahim was not seen by a doctor and no formal follow Up meeting was arranged, Mr Ladak-Ebrahim contacted his GP on the 10"h October 2012 and the GP sent a fax to Brent Assessment and Brief Treatment Team requesting an urgent assessment On the 11' October 2012 at 13.29 hrs a nurse contacted Mr Ladak-Ebrahim by telephone and it is likely at that time he was at an immediate risk of harming himself. The Nurse wanted Mr Ladak-Ebrahim to be seen by a doctor but was told that no doctor was available and a referral was made to the Home Treatment Team: The referral to the Home Treatment Team was not accepted until the nurse spoke to the Home Treatment Team the next Mr Ladak-Ebrahim had been found _having_hanged himself at his_home on the evening of Day day Day day: the 17"n October 2012_

Circumstances of the death

Mr Ladak-Ebrahim had contact with a number of health care professionals and was living at home with his mother. Had Mr Ladak-Ebrahim's mother been told that he was at an immediate risk of self-harm she would have ensured that he was not left alone_

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:

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Shared signals

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Report details

Reference: 2013-0278
Date of report: 5 November 2013
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: 31 Dec 2013 (estimated).

Sent to

Department of Health

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.