Barbara Mayer
PFD Report
All Responded
Ref: 2015-0113
All 1 response received
· Deadline: 22 May 2015
Response Status
Responses
1 of 1
56-Day Deadline
22 May 2015
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroners Concerns
In the circumstances it is my statutory to report to you: Mn was noted to show signs of Carer fatigue_but this was not followed Mary history day: duty up; (2) Although seen regularly by the Crisis Team, Mrs Mayer was seen by a number of different people as a result of which no trusting relalionship could be established. She had to repeat her history at each visit t0 a different person about personal matters (3) Different treatments were offered to Mrs Mayer without (he reasoning or their efficacy being discussed with her: (4) Mrs Mayer required help urgently on 14 November 2014 but due to an increase in demand no one was available to see her until 16 November 2014. It is understood Doclors are now called out and an On call Manager can be contacted in such situations
Responses
Response received
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Dear Ms Lake Regulation 28 report following the inquest of Mrs Barbara Mayer on 11 March 2015 write in response to your report dated 23 March 2015, Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the death of Mrs Mayer on 11 March 2015. You recorded four areas giving rise to concern: will address these in order: was showing signs of carer fatigue, but this was not followed up Caring for someone with mental health needs is a challenging experience and can have mental and physical effects. It is imperative that carers are supported in (heir role and provided with proportionale assistance when required: In (case we did not fully appreciate the impact of caring was having: For this, the Trust apologises_ The Trust is implementing the 'Triangle of Care' model which prescribes a therapeutic alliance between service user, carer and staff member that promotes safety, supports recovery and suslains wellbeing: The model, created by the Carers Trust, is aimed at partnership working: The Trust is nearing completion of the first stage of this multi year plan: This involved services completing a self assessment tool, creating an action plan for areas requiring development: The Trust Execulive hear regular updates on its progress as we are committed to significant cultural change in how we engage and support carers Chair: Page Chief Executive: Michael Scott 3 MINDFUL Trust Headquarters: Hellesdon Hospital, Stonewall EMPLOYER Drayton High Road, Norwich; NR6 SBE DMMREMYCULMFiOH Tel: 01603 421421 Fax: 01603 421440
May Gary AbOur Ative_ 1 O15ABL 69
Ms Lake "22-
2. Although seen regularly by the Crisis Team, Mrs Mayer was seen by a number of different people as a result of which no trusting relationship could be established. She had to repeat her history at each visit to a different person about personal matters: The Crisis Resolution and Home Treatment (CRHT) team provide a 24 hour service, assessing and supporting service users with intensive treatment for defined periods of time. It has a team of fifty staff supporting a significant number of people across a large geographical area. These factors mean that planning and coordinating consistent staff contact with a service user is a challenge_ The Trust recognises the impact this can have for service users and their carers, especially during times of crisis_ The Trust is planning to review the functions of the CRHT over the forthcoming months_ Included within this review will be how we can improve the consistency of staff engaged with lhe service user, would to provide you with an update on progress in early September _
3. Different treatments were offered to Mrs Mayer without the reasoning or their efficacy being discussed, This is recognised to be important because it is difficult to make informed decisions if the individual is not in receipt of all the required information; The Trust supports the best practice of informed decision making and is sorry this was not evident for Mrs Mayer This is an area of practice which has significance across the The Trust will be emphasising this aspect of practice through its structures for learning, such as clinical forums and patient safety newslelter_
4. Mrs Mayer required help urgently on 14 November 2014 but due to an increase in demand no one was available to see her until 16 November 2014. It Is understood Doctors are now called out and an on call manager can be contacted in such situations. This was a contributory factor in the events leading lo Mrs Mayer's dealh: The is sorry that significant demand for the CRHT team meant they could not visit Mrs Mayer until late on Saturday 15 November 2014. As Mrs Mayer was going to sleep it was appropriate to agree to defer Ihe visit until the next day. Mrs Mayer died during the night. The Trust is experiencing increasing demands for all of its services at a time of being challenged to make savings. It is recognised that when services such as the CRHT team reach levels of capacity there has to be robust mechanisms for escalation and contingency: To this end the localities across the Trust are reviewing their escalation plans for services such as CRHT and the Dementia Intensive Support Teams, both of which are required to respond to incoming referrals_ Thank you for raising these matters of concern, as align with the Trust's desire to take all available learning from this tragic event; propose to write in September with an update of the CRHT review and contingency plans but if can be of any further assistance please do not hesitate lo contact me_
May Gary AbOur Ative_ 1 O15ABL 69
Ms Lake "22-
2. Although seen regularly by the Crisis Team, Mrs Mayer was seen by a number of different people as a result of which no trusting relationship could be established. She had to repeat her history at each visit to a different person about personal matters: The Crisis Resolution and Home Treatment (CRHT) team provide a 24 hour service, assessing and supporting service users with intensive treatment for defined periods of time. It has a team of fifty staff supporting a significant number of people across a large geographical area. These factors mean that planning and coordinating consistent staff contact with a service user is a challenge_ The Trust recognises the impact this can have for service users and their carers, especially during times of crisis_ The Trust is planning to review the functions of the CRHT over the forthcoming months_ Included within this review will be how we can improve the consistency of staff engaged with lhe service user, would to provide you with an update on progress in early September _
3. Different treatments were offered to Mrs Mayer without the reasoning or their efficacy being discussed, This is recognised to be important because it is difficult to make informed decisions if the individual is not in receipt of all the required information; The Trust supports the best practice of informed decision making and is sorry this was not evident for Mrs Mayer This is an area of practice which has significance across the The Trust will be emphasising this aspect of practice through its structures for learning, such as clinical forums and patient safety newslelter_
4. Mrs Mayer required help urgently on 14 November 2014 but due to an increase in demand no one was available to see her until 16 November 2014. It Is understood Doctors are now called out and an on call manager can be contacted in such situations. This was a contributory factor in the events leading lo Mrs Mayer's dealh: The is sorry that significant demand for the CRHT team meant they could not visit Mrs Mayer until late on Saturday 15 November 2014. As Mrs Mayer was going to sleep it was appropriate to agree to defer Ihe visit until the next day. Mrs Mayer died during the night. The Trust is experiencing increasing demands for all of its services at a time of being challenged to make savings. It is recognised that when services such as the CRHT team reach levels of capacity there has to be robust mechanisms for escalation and contingency: To this end the localities across the Trust are reviewing their escalation plans for services such as CRHT and the Dementia Intensive Support Teams, both of which are required to respond to incoming referrals_ Thank you for raising these matters of concern, as align with the Trust's desire to take all available learning from this tragic event; propose to write in September with an update of the CRHT review and contingency plans but if can be of any further assistance please do not hesitate lo contact me_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has (he power to take such action:
Report Sections
Investigation and Inquest
On 17 November 2014 commenced an investigation into the death of Barbara Anne Mayer Aged 72 years. The investigation concluded at the end of the inquest on 11 March 2015. The conclusion of the inquest was medical cause of death: drowning; and conclusion: "Suicide whilst under the care of Mental Heallh Services"_
Circumstances of the Death
Mrs Mayer had a long of depression. Her anxiety increased in 2013 when she suffered a number of physical health problems. She was reviewed regularly by her GP who referred her for a menlal health assessment in September 2014. Her care was passed to the Dementia and Complexity in Later Life Team: She conlinued to ask her husband to help her end her life_ She was discharged by the Crisis Team to the Community Mental Health Team on 15 October 2014. Her GP referred her back to the Crisis Team for assessment on 12 November 2014 On 14 November 2014, Mrs Mayer begged her husband t0 help drown her in the bath_ called the Crisis Team who were unable to attend due to levels of work elsewhere. Her Care Co-Ordinator did attend to see her; Iwas contacted by the Crisis Team to say someone would be visiting that At 21:15 hours a telephone call was made to say someone would attend after midnight for an assessment: As Mrs Mayer had taken sleeping medication and was getting ready for bed, it was agreed someone would call to see her the next morning: At some time between 02:00am and 05.OOam Mrs Mayer left the house, leaving a pillow in her bed in place of her body: She was found on 16 November 2014 drowned in a nearby pond.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.