Bryan and Mary Andrews
PFD Report
All Responded
Ref: 2024-0532
All 1 response received
· Deadline: 29 Nov 2024
Response Status
Responses
1 of 1
56-Day Deadline
29 Nov 2024
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
There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
Responses
The Trust's Single Point of Access Service is no longer operational due to a transformation programme. They plan to ensure neurology departments receive electronic copies of crisis assessments for shared service users, include discharge summaries in annual record keeping audits, and establish a six-monthly shared learning forum with the Neurology Department.
AI summary
View full response
Dear Mrs Rawden
I am writing in response to the Regulation 28 Report to Prevent Future Deaths received following the inquest relating to the deaths of Mr Bryan and Mrs Mary Andrews, heard between 1st and 2nd October 2024. SHSC is saddened by their deaths and have taken your concerns very seriously. We are confident we can learn from this and improve the standards of care to mitigate, as far as possible, similar circumstances happening again.
You raised concerns in relation to a lack of communication between services regarding the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths, which you outlined led to significant time lapses in treatment and the rejection of referrals.
In providing this response, we have worked collaboratively with colleagues from Sheffield Teaching Hospitals NHS Foundation Trust, in particular, with colleagues from the Neurology Department.
The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:
1. When a service user, who is known to be receiving treatment from the Neurology Department, has a crisis assessment undertaken, an electronic copy of the crisis assessment and outcome/plan will be provided to the Neurology Department. This will ensure the appropriate specialists are aware of current concerns and risks relating to the service user.
2. Discharge summaries are electronically sent to GPs through our electronic patient record system. In this case, although the discharge summary was created on 9 May 2022, the day of discharge, it was further edited on 13 May 2022. It appears that because the discharge
summary remained in ‘draft’, it was not sent as a finalised document. We have included discharge summaries within our annual record keeping audits that we undertake within each service, to ensure the summaries are sent to GPs and are of a quality that meets our required standards.
3. We believe that strengthening relationships, specifically with the Neurology Department, will be beneficial for both organisations and for our shared care service users. We have committed to establishing a six-monthly shared learning forum to engender understanding of the interactions between neurological disorders, such as epilepsy and mental health problems.
I trust that this addresses the issues raised to your satisfaction. These actions will be monitored and reported to the Executive Team and Trust Board. Please do not hesitate to contact us if you require any additional information regarding our actions.
May I again extend my sincere condolences to Mr & Mrs Andrews’s family.
I am writing in response to the Regulation 28 Report to Prevent Future Deaths received following the inquest relating to the deaths of Mr Bryan and Mrs Mary Andrews, heard between 1st and 2nd October 2024. SHSC is saddened by their deaths and have taken your concerns very seriously. We are confident we can learn from this and improve the standards of care to mitigate, as far as possible, similar circumstances happening again.
You raised concerns in relation to a lack of communication between services regarding the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths, which you outlined led to significant time lapses in treatment and the rejection of referrals.
In providing this response, we have worked collaboratively with colleagues from Sheffield Teaching Hospitals NHS Foundation Trust, in particular, with colleagues from the Neurology Department.
The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:
1. When a service user, who is known to be receiving treatment from the Neurology Department, has a crisis assessment undertaken, an electronic copy of the crisis assessment and outcome/plan will be provided to the Neurology Department. This will ensure the appropriate specialists are aware of current concerns and risks relating to the service user.
2. Discharge summaries are electronically sent to GPs through our electronic patient record system. In this case, although the discharge summary was created on 9 May 2022, the day of discharge, it was further edited on 13 May 2022. It appears that because the discharge
summary remained in ‘draft’, it was not sent as a finalised document. We have included discharge summaries within our annual record keeping audits that we undertake within each service, to ensure the summaries are sent to GPs and are of a quality that meets our required standards.
3. We believe that strengthening relationships, specifically with the Neurology Department, will be beneficial for both organisations and for our shared care service users. We have committed to establishing a six-monthly shared learning forum to engender understanding of the interactions between neurological disorders, such as epilepsy and mental health problems.
I trust that this addresses the issues raised to your satisfaction. These actions will be monitored and reported to the Executive Team and Trust Board. Please do not hesitate to contact us if you require any additional information regarding our actions.
May I again extend my sincere condolences to Mr & Mrs Andrews’s family.
Report Sections
Investigation and Inquest
On 28 November 2022 I commenced investigations into the deaths of Bryan Andrews aged 79, and Mary Andrews aged 76. The investigation concluded at the end of the inquests on 2 October 2024. The conclusion of the inquests was unlawful killing. The medical cause of death was: 1a. Multiple stab wounds.
Circumstances of the Death
On 27 November 2022 Bryan and Mary Andrews died at their home address of due to multiple stab wounds inflicted by their adult son. Their son had epilepsy caused by an area of abnormal brain development in the right frontal lobe. He continued to have regular seizures despite the medication he was taking. He had a documented history of postictal psychosis. The Court heard his frontal lobe epilepsy created a risk around how he responded to experiences of postictal psychosis. His mental health had deteriorated significantly in the two years before his parents died. Seven months before his parents died, he reported thoughts of wanting to kill someone. In police interview, he admitted to killing his parents and attempting to end his own life by inflicting a knife wound in his abdomen. He pleaded guilty to murder on the grounds of diminished responsibly and was sentenced to an indefinite hospital order.
Copies Sent To
ii. Sheffield Teaching Hospitals NHS Foundations Trust
iii. , Consultant neurologist
iv. , Domestic Homicide review author
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.