Martin Barrett
PFD Report
All Responded
Ref: 2020-0222
All 1 response received
· Deadline: 26 Dec 2020
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
26 Dec 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
During oral evidence, I was advised that when an onwards internal referral is made to another clinician within the Priory Group which is then declined this is not communicated directly to the patient if the treatment is funded by way of insurance cover. In those cases a notification would be provided to the insurers or the policyholder and then the Priory Group would not have any further contact with the patient. As such, patients that are considered to be higher risk by the clinician at initial assessment may not therefore have the opportunity to imminently consider alternative sources of treatment or receive any advice as to safety netting in the interim as this information is not being provided by clinicians to the patient. From the evidence that I heard it would be reliant on their insurers or corporate policy holders (who may well not be clinicians) to make contact with the patients to inform them of this during which time their health may have further declined or their risk increased.
Responses
Response received
View full response
Dear Ms Andrews
Death of Mr Martin Thomas Barrett; Date of birth: 21 October 1977 – Date of death: 25 February 2020
I am writing in response to the Regulation 28 Report dated Tuesday 3 November 2020 issued following the Inquest touching the death of Mr Martin Thomas Barrett.
Your Regulation 28 Report identifies that arrangements should be put in place so that newly- referred clients with a higher risk profile are provided with advice on how to secure alternative treatment (rather than this being the responsibility of the insurers or corporate policyholders).
We have given due consideration to the concerns raised and our response is provided below.
Corporate Client Team arrangements
Please note that direct contact is now made by the Corporate Client Team (CCT) with all newly referred clients following treatment authorisation. An e-mail will be sent in the event that the newly referred client cannot be reached by telephone.
Guidance has been put in place for the CCT on the actions to take if a client is experiencing an immediate crisis. The guidance includes a script to be used by the staff member to instruct the client to make contact with their family, friends or colleagues or crisis counselling services. Additionally the script makes reference on how to obtain emergency professional assistance (for example, by attending their nearest accident and emergency department).
2
Therapist arrangements
In order to secure prompt clinical input, an appointment with a consultant psychiatrist is now booked to take place in the same week as the therapy assessment. The appointment is released should the outcome of the therapy assessment be that the consultant psychiatrist assessment is not required.
Therapists have also been given guidance – similar to that outlined above – on the advice that they should give to any newly referred clients who they feel are higher risk. They have also been reminded that it is not always possible for an assessment by a consultant psychiatrist to take place on the same day as the initial therapy assessment and this needs to be taken into account when providing advice and guidance to a higher risk client.
Documentation and communication
The CCT and the therapists have been reminded that they should document their interventions and must communicate with each other and the newly referred client promptly – they should not expect this to be the responsibility of the insurer or corporate policyholder. Audits of client contacts will be carried out by the CCT from time to time in order to ensure this aim is achieved.
I trust that the actions outlined above will provide the assurances you seek in respect of this matter.
Yours sincerley
Chief Executive Officer Priory Group
Death of Mr Martin Thomas Barrett; Date of birth: 21 October 1977 – Date of death: 25 February 2020
I am writing in response to the Regulation 28 Report dated Tuesday 3 November 2020 issued following the Inquest touching the death of Mr Martin Thomas Barrett.
Your Regulation 28 Report identifies that arrangements should be put in place so that newly- referred clients with a higher risk profile are provided with advice on how to secure alternative treatment (rather than this being the responsibility of the insurers or corporate policyholders).
We have given due consideration to the concerns raised and our response is provided below.
Corporate Client Team arrangements
Please note that direct contact is now made by the Corporate Client Team (CCT) with all newly referred clients following treatment authorisation. An e-mail will be sent in the event that the newly referred client cannot be reached by telephone.
Guidance has been put in place for the CCT on the actions to take if a client is experiencing an immediate crisis. The guidance includes a script to be used by the staff member to instruct the client to make contact with their family, friends or colleagues or crisis counselling services. Additionally the script makes reference on how to obtain emergency professional assistance (for example, by attending their nearest accident and emergency department).
2
Therapist arrangements
In order to secure prompt clinical input, an appointment with a consultant psychiatrist is now booked to take place in the same week as the therapy assessment. The appointment is released should the outcome of the therapy assessment be that the consultant psychiatrist assessment is not required.
Therapists have also been given guidance – similar to that outlined above – on the advice that they should give to any newly referred clients who they feel are higher risk. They have also been reminded that it is not always possible for an assessment by a consultant psychiatrist to take place on the same day as the initial therapy assessment and this needs to be taken into account when providing advice and guidance to a higher risk client.
Documentation and communication
The CCT and the therapists have been reminded that they should document their interventions and must communicate with each other and the newly referred client promptly – they should not expect this to be the responsibility of the insurer or corporate policyholder. Audits of client contacts will be carried out by the CCT from time to time in order to ensure this aim is achieved.
I trust that the actions outlined above will provide the assurances you seek in respect of this matter.
Yours sincerley
Chief Executive Officer Priory Group
Report Sections
Investigation and Inquest
On 9 March 2020 I commenced an investigation into the death of Martin Thomas BARRETT. The investigation concluded at the end of the inquest . The conclusion of the inquest was that Mr Barrett had taken his own life on 25 February 2020 and as such I gave a conclusion of suicide The medical cause of death after post mortem was 1a Suspension by the Neck 1b 1c
Circumstances of the Death
6 Mr Martin Thomas Barrett took part in a telephone consultation assessment with the Priory Group by a Cognitive Behavioural Therapist for anxiety at 8am on the morning of his death. During that assessment, he stated that he had thought about suicide and planned how this may occur but did not indicate any immediate intent. The Therapist informed the Court that she considered that he was high risk of suicide but that he had engaged with her safety planning and had agreed to take steps to keep himself safe. The Therapist therefore made an internal referral for a same day appointment with a Consultant Psychiatrist at the Priory Group for further assessment. This referral was made after the appointment and considered by the Consultant after his morning clinic which was around lunchtime. The Psychiatrist declined the referral as he considered that the needs of Mr Barrett were too complex and would be better resolved within the NHS. This decision was not communicated to Mr Barrett. Sadly he was found hanging at his home address around 3pm that day. CORONER’S CONCERNS During 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – During oral evidence, I was advised that when an onwards internal referral is made to another clinician within the Priory Group which is then declined this is not communicated directly to the patient if the treatment is funded by way of insurance cover. In those cases a notification would be provided to the insurers or the policyholder and then the Priory Group would not have any further contact with the patient. As such, patients that are considered to be higher risk by the clinician at initial assessment may not therefore have the opportunity to imminently consider alternative sources of treatment or receive any advice as to safety netting in the interim as this information is not being provided by clinicians to the patient. From the evidence that I heard it would be reliant on their insurers or corporate policy holders (who may well not be clinicians) to make contact with the patients to inform them of this during which time their health may have further declined or their risk increased. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the Priory Group has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 December 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 27 October 2020 9 Signature Joanne Andrews Area Coroner for North East Kent
COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 27 October 2020 9 Signature Joanne Andrews Area Coroner for North East Kent
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.