Safoora Alam
PFD Report
All Responded
Ref: 2019-0426
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
All 2 responses received
· Deadline: 3 Feb 2020
Response Status
Responses
2 of 2
56-Day Deadline
3 Feb 2020
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
Coroner’s Concerns
1. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the agencies involved.
2. There was a lack of a joint Mental Health Trust and social care packages for patients with complex physical health needs or opportunities to convene multi-agency meetings.
3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took place.
4. The Local authority housing officers did recognise the escalating risk in her mental health state but the mechanism for urgent referral via the safeguarding team and GP was a slow and cumbersome process which didn’t work.
2. There was a lack of a joint Mental Health Trust and social care packages for patients with complex physical health needs or opportunities to convene multi-agency meetings.
3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took place.
4. The Local authority housing officers did recognise the escalating risk in her mental health state but the mechanism for urgent referral via the safeguarding team and GP was a slow and cumbersome process which didn’t work.
Responses
Response received
View full response
Dear Mr Siddique
Thank you for your report regarding Ms Alam’s inquest, and the concerns raised from the evidence revealed during the course of the inquest.
I can confirm the Service Manager from Social Work and Therapy has reviewed the concerns and actions identified, which has resulted the following outcomes.
In relation to our approaches to sharing information of risk. The Service Manager of Social Work and Therapy, and the Service Manager of Neighbourhoods have met and reviewed the identified concerns and actions within the report. As a result an operational group has been set up to explore and develop a vulnerable adult risk management protocol.
In relation to point 2, an action for Social Services to consider reviewing their training for social workers, obtaining accurate and up to date information prior to any visit. A review of our current practice guidance is being undertaken, and lessons learnt will be shared with all staff groups, through team meeting sessions.
In order to be assured of the robustness of our joint agency protocols. I can confirm the Service Manager of Social Work and Therapy has made contact with Urgent Care Manager, Mental Health Trust, and there are plans in place to undertake a review of our current protocols within the next four weeks.
I trust the information provided will satisfy you that we have acknowledged and responded to the concerns and actions identified.
Thank you for your report regarding Ms Alam’s inquest, and the concerns raised from the evidence revealed during the course of the inquest.
I can confirm the Service Manager from Social Work and Therapy has reviewed the concerns and actions identified, which has resulted the following outcomes.
In relation to our approaches to sharing information of risk. The Service Manager of Social Work and Therapy, and the Service Manager of Neighbourhoods have met and reviewed the identified concerns and actions within the report. As a result an operational group has been set up to explore and develop a vulnerable adult risk management protocol.
In relation to point 2, an action for Social Services to consider reviewing their training for social workers, obtaining accurate and up to date information prior to any visit. A review of our current practice guidance is being undertaken, and lessons learnt will be shared with all staff groups, through team meeting sessions.
In order to be assured of the robustness of our joint agency protocols. I can confirm the Service Manager of Social Work and Therapy has made contact with Urgent Care Manager, Mental Health Trust, and there are plans in place to undertake a review of our current protocols within the next four weeks.
I trust the information provided will satisfy you that we have acknowledged and responded to the concerns and actions identified.
Response received
View full response
Dear Mr Siddique,
Re. Regulation 28 report, prevention of future death pertaining to Ms Safoora Alam, deceased.
Firstly on behalf of Black Country Partnership NHS Foundation Trust may I extend our most sincere condolences to the family of Ms Alam.
During the course of the inquest the evidence revealed matters giving rise to concerns in such a way that there is a risk that future deaths will occur unless action is taken. In response to your regulation 28 report to prevent future deaths we have outlined below the actions, Black Country Partnership has taken with the Local Authority to address the matters of concern that affected our organisation.
1. All agencies involved may wish to consider reviewing their approaches to sharing of information and approaches to multidisciplinary risk assessments for patients with these complex needs.
Currently both organisations hold multidisciplinary risk assessment meetings in isolation, particularly since the section 75 agreement was disbanded. There is recognized a difficulty in communication between departments in this matter which needs to be resolved. As a response, the General Manager for BCPFT Urgent Care Services has met with the Service Manager for Clinical Services from the Local Authority to examine how our individual organizational processes can be optimized and joined going forward in order to prevent gaps in services.
Both senior managers were able to identify common goals and aims in existing organizational protocols and will instigate a steering group of senior clinicians and managers from both organisations to look at introducing joint complex care panels that will look at risk assessments for patients with complex needs that require joint information sharing and joint working.
It is proposed that these joint multidisciplinary complex case panels will occur monthly and be chaired on a rotational agreement by a General
Headquarters Delta House Delta Point Greets Green Road West Bromwich B70 9PL
Tel: 0845 146 1800 Fax: 0121 612 8090 Web: www.bcpft.nhs.uk
Manager from Black Country Partnership and Service Manager from the Local Authority. The joint multidisciplinary panel will determine which is the lead organisation in each case where there is disagreement and also ensure that the joint resources from both organisations are employed when discussing individual care plans and risk assessments.
2. Social Services may wish to consider reviewing their training for the social workers involved and the importance of obtaining accurate and up to date information prior to any visit.
This concern and supporting action is for the Local Authority to respond to.
3. The Mental Health Trust in conjunction with the local authority may wish to consider reviewing their joint agency protocols and developing multi- agency protocols to learn from this tragic incident.
The section 75 agreement whereby the local authority delegates responsibility to the local NHS organisation in this case Black Country Partnership has been disbanded. This has meant that services have developed independently from each other and that where services and departments used to work together and oftentimes cohabit office space, this no longer happens. Both organisations have joint protocols for working together but in a majority of cases, it is accepted that staff do not understand their counterpart service nor who to contact in the local authority and vise versa.
The General Manager for Urgent Care Services for Black Country Partnership and the Service Manager for the Local Authority have met to examine communication and interface between the two organisations. They agreed that communication and interface is often poor due to that both organisations have different departments and terminology in services which can cause confusion. This is augmented by the fact that staff and senior staff are not aware of who their counterpart is and how to contact them in some cases.
The General Manager for Black Country Partnership and the Service Manager for the Local Authority have agreed to set up task and finish groups to look at joint agency protocols in both organizations and review them. Furthermore, they agreed that there should be a joint database or protocol which contains all contacts and services that each organisation provides. This will provide staff with an up to date contact list of services in order to support and promote joint working.
Both senor managers agreed to include on the database and in joint agency protocols the hierarchy and structures of services so that there is a governance and escalation process.
Please note that concern number 2 is for the local authority to examine and therefore BCPFT have not commented on this outcome.
The senior managers also agreed to consider engaging in a wider learning event to consider outcomes and where future processes can be continued to be strengthened.
I hope this provides you with assurance that the Trust has taken the concerns raised in your regulation 28 response very seriously and will continue to take action to reduce the likelihood of a similar incident from reoccurring. We hope that the actions highlighted above will make a difference and we will review changes made at regular intervals to ensure that they are embedded whilst sharing the outcome and lessons learnt with all affected staff.
Re. Regulation 28 report, prevention of future death pertaining to Ms Safoora Alam, deceased.
Firstly on behalf of Black Country Partnership NHS Foundation Trust may I extend our most sincere condolences to the family of Ms Alam.
During the course of the inquest the evidence revealed matters giving rise to concerns in such a way that there is a risk that future deaths will occur unless action is taken. In response to your regulation 28 report to prevent future deaths we have outlined below the actions, Black Country Partnership has taken with the Local Authority to address the matters of concern that affected our organisation.
1. All agencies involved may wish to consider reviewing their approaches to sharing of information and approaches to multidisciplinary risk assessments for patients with these complex needs.
Currently both organisations hold multidisciplinary risk assessment meetings in isolation, particularly since the section 75 agreement was disbanded. There is recognized a difficulty in communication between departments in this matter which needs to be resolved. As a response, the General Manager for BCPFT Urgent Care Services has met with the Service Manager for Clinical Services from the Local Authority to examine how our individual organizational processes can be optimized and joined going forward in order to prevent gaps in services.
Both senior managers were able to identify common goals and aims in existing organizational protocols and will instigate a steering group of senior clinicians and managers from both organisations to look at introducing joint complex care panels that will look at risk assessments for patients with complex needs that require joint information sharing and joint working.
It is proposed that these joint multidisciplinary complex case panels will occur monthly and be chaired on a rotational agreement by a General
Headquarters Delta House Delta Point Greets Green Road West Bromwich B70 9PL
Tel: 0845 146 1800 Fax: 0121 612 8090 Web: www.bcpft.nhs.uk
Manager from Black Country Partnership and Service Manager from the Local Authority. The joint multidisciplinary panel will determine which is the lead organisation in each case where there is disagreement and also ensure that the joint resources from both organisations are employed when discussing individual care plans and risk assessments.
2. Social Services may wish to consider reviewing their training for the social workers involved and the importance of obtaining accurate and up to date information prior to any visit.
This concern and supporting action is for the Local Authority to respond to.
3. The Mental Health Trust in conjunction with the local authority may wish to consider reviewing their joint agency protocols and developing multi- agency protocols to learn from this tragic incident.
The section 75 agreement whereby the local authority delegates responsibility to the local NHS organisation in this case Black Country Partnership has been disbanded. This has meant that services have developed independently from each other and that where services and departments used to work together and oftentimes cohabit office space, this no longer happens. Both organisations have joint protocols for working together but in a majority of cases, it is accepted that staff do not understand their counterpart service nor who to contact in the local authority and vise versa.
The General Manager for Urgent Care Services for Black Country Partnership and the Service Manager for the Local Authority have met to examine communication and interface between the two organisations. They agreed that communication and interface is often poor due to that both organisations have different departments and terminology in services which can cause confusion. This is augmented by the fact that staff and senior staff are not aware of who their counterpart is and how to contact them in some cases.
The General Manager for Black Country Partnership and the Service Manager for the Local Authority have agreed to set up task and finish groups to look at joint agency protocols in both organizations and review them. Furthermore, they agreed that there should be a joint database or protocol which contains all contacts and services that each organisation provides. This will provide staff with an up to date contact list of services in order to support and promote joint working.
Both senor managers agreed to include on the database and in joint agency protocols the hierarchy and structures of services so that there is a governance and escalation process.
Please note that concern number 2 is for the local authority to examine and therefore BCPFT have not commented on this outcome.
The senior managers also agreed to consider engaging in a wider learning event to consider outcomes and where future processes can be continued to be strengthened.
I hope this provides you with assurance that the Trust has taken the concerns raised in your regulation 28 response very seriously and will continue to take action to reduce the likelihood of a similar incident from reoccurring. We hope that the actions highlighted above will make a difference and we will review changes made at regular intervals to ensure that they are embedded whilst sharing the outcome and lessons learnt with all affected staff.
Action Should Be Taken
[IL1: PROTECT]
1. All agencies involved may wish to consider reviewing their approaches to sharing of information and approaches to multidisciplinary risk assessments for patients with these complex needs.
2. Social Services may wish to consider reviewing their training for the social workers involved and the importance of obtaining accurate and up to date information prior to any visit.
3. The Mental Health Trust in conjunction with the local authority may wish to consider reviewing their joint agency protocols and developing multi-agency protocols to learn from this tragic incident.
1. All agencies involved may wish to consider reviewing their approaches to sharing of information and approaches to multidisciplinary risk assessments for patients with these complex needs.
2. Social Services may wish to consider reviewing their training for the social workers involved and the importance of obtaining accurate and up to date information prior to any visit.
3. The Mental Health Trust in conjunction with the local authority may wish to consider reviewing their joint agency protocols and developing multi-agency protocols to learn from this tragic incident.
Report Sections
Investigation and Inquest
On the 30 January 2019, I commenced an investigation into the death of Ms Safoora Alam. The investigation concluded at the end of the inquest on 8 November 2019. The conclusion of the inquest was a short form conclusion of suicide. The cause of death was:
1a Inhalational Burns b Severe Flame Burns
1a Inhalational Burns b Severe Flame Burns
Circumstances of the Death
i) Ms Alam had complex physical health problems which included a reported diagnosis of Ehlers Syndrome and Fibromyalgia. She had previously suffered a stroke and had on-going complications including pain and mobility issues. ii) She had become increasingly frustrated about her accommodation and her perceived lack of engagement by the agencies involved in her care to find practical solutions to help her with her physical health needs. These included the provision of a ramp. She ultimately decided she would prefer to be in supported accommodation. iii) On several occasions she had threatened to self-harm and had taken impulsive overdoses. A referral was made to the mental health team and the Consultant Psychiatrist’s assessment at this time (12 December 2018) indicated that the patient was not suicidal, not depressed, and not psychotic. iv) The Consultant Psychiatrist recorded that the patient was projecting responsibility to services, had traits of personality disorder, was angry and abusive. v) On the 7 January 2019 a further referral was made to the Crisis Home Treatment Team (CHTT) after another overdose attempt. She denied any
[IL1: PROTECT] on-going suicidal ideation and was discharged back to her GP. vi) On the 25 January the CHTT were contacted by the Social Worker. The patient had attended Russells Hall Hospital via an ambulance after having been found by her carers with her gas cooker left on and a lit cigarette. Her gas supply was disconnected, and she was given an electrical fan heater. vii) She was visited by the CHTT again and reported fleeting suicidal thoughts due to her physical health problems. She reported no active plans to end her life at the time of the assessment. Her risk of suicide was deemed to be low, however it was noted that this could be escalated due to impulsive behaviours. viii) On the morning of the 28 January 2019 she had a visit from her Social workers for an assessment. However, this wasn’t completed due to a reported hostile reception they received. ix) She was further visited by housing officers from the local authority and they noted a worrying decline in her mental state and referred her through to their safeguarding department and her GP for a mental health assessment. x) She was last visited by her carers in the afternoon and seemed to have been in better mood. Later that afternoon, she was discovered in her bedroom and had set fire to her bed and herself. She sustained at least 80% burns to her body and sadly died from her injuries later that day at Queen Elizabeth Hospital.
[IL1: PROTECT] on-going suicidal ideation and was discharged back to her GP. vi) On the 25 January the CHTT were contacted by the Social Worker. The patient had attended Russells Hall Hospital via an ambulance after having been found by her carers with her gas cooker left on and a lit cigarette. Her gas supply was disconnected, and she was given an electrical fan heater. vii) She was visited by the CHTT again and reported fleeting suicidal thoughts due to her physical health problems. She reported no active plans to end her life at the time of the assessment. Her risk of suicide was deemed to be low, however it was noted that this could be escalated due to impulsive behaviours. viii) On the morning of the 28 January 2019 she had a visit from her Social workers for an assessment. However, this wasn’t completed due to a reported hostile reception they received. ix) She was further visited by housing officers from the local authority and they noted a worrying decline in her mental state and referred her through to their safeguarding department and her GP for a mental health assessment. x) She was last visited by her carers in the afternoon and seemed to have been in better mood. Later that afternoon, she was discovered in her bedroom and had set fire to her bed and herself. She sustained at least 80% burns to her body and sadly died from her injuries later that day at Queen Elizabeth Hospital.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.