Rowena Golton
PFD Report
All Responded
Ref: 2014-0486
All 1 response received
· Deadline: 6 Jan 2015
Response Status
Responses
1 of 1
56-Day Deadline
6 Jan 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
Coroner's Concerns
Evidence was given as to the lack of availability of psychological services within the crisis teams. Following her admission as an inpatient she was then under the care of the crisis team: Not all crisis teams have access to a psychologist and the internal investigation recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access_ In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases
Responses
Response received
View full response
Dear Ms Kearsley Re: Rowena Kathryn Golton (Deceased) Further to your letter dated 5th January 2015 would like to provide a response to vour points raised We have not; as yet, received any information from Manchester Mental Health and Social Care Trust in relation to the lack of availability of psychological therapies in crisis teams Head of Mental Health Improvement Programme, is working closely with colleagues to review service provision across all services and to develop care pathways for service users. With regards to Manchester Mental Health and Social Care Trust response indicating that they have reviewed access to clinical psychology services can confirm that the Citywide Team commissioned a review of psychological therapies (IAPT) with two providers of this service in Manchester; Manchester Mental Health and Social Care Trust one of the providers reviewed. assume that this review is what the Trust response relates to a5 am not aware of any separate review of IAPT being undertaken. The National IAPT Intensive Support Team was asked to undertake a diagnostic review of the Citywide IAPT services. The review was requested by Commissioners in response to our low Derformance for the national indictors and the need to achieve 15% access to psychological therapies in line with the IAPT programme and the waiting lists_ An external and expert review was required to understand why performance is low: The subsequent report offered number of options to consider to more effectively offer NICE recommended therapies for mild to moderate-severe anxiety and depression, and Step psychological therapies (IAPT). As a result both commissioners and providers are working together to implement the recommendations of the report: We aim to increase access to psychological therapies by increasing productivity of services currently commissioned and to align other commissioned services to this pathway of care: With regards to the waiting time for access to psychological therapies information supplied in your letter by Manchester Mental Health and Social Care Trust would like make the following comments_ The information in your letter details the activity levels for Clinical Psychology and Psychotherapy Service in relation to step psychological therapies. This information was Trust the being long help Step
sent to me in a letter by (Director of Operations, MMHSCT) on the 23rd December 2014. In her lettel proposed the closure of the waiting list for complex cases from the 1s February 2015 until the 18 week referral to treatment pathway can be delivered by the Trust: was unable to support this proposal due to patient safety risks_ Following the National IAPT team review and the examination of the Psychological Therapies CQUIN that is in place relating to waiting times, Commissioners now have better understanding of how the manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are taken by the Trust to regularly cleanse and review the number of patients waiting: We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data. The Trust have indicated areas of significant pressure and that complex cases service are exceeding 'the available commissioned resource" Within the block contract in place there is no specific allocation for this service or any other Psychological Therapies, with the exception of IAPT, and so am unsure what the Trust considers 'the available commissioned resource' is_ We have recently made a request tol ((Director of Finance) at the Contracts Meeting with the Trust for information regarding the level of Psychological Therapy input into inpatient and community services to understand which services have input and which do not: As commissioners we do not have access to this information and although some existing service specifications detail psychological therapy input it has become evident that some services do not have the access we believed was available and we need a clear picture across the Trust services_ We have also asked for clarification the Trust as to why have identified Psychological Therapies within its Cost Improvement Programme (CIP) plan when there are such long waiting lists. For the past few years the Trust has identified significant contribution toward its CIP plan vacancies within the Psychological Therapy service budget and the letter from the Trust indicated that 'without additional investment the service does not have sufficient commissioned resource to address its historical waiting list and provide timely access to newly referred clients' have made it clear to Manchester Mental Health and Social Care Trust that do not support Psychological Therapies included within CIP plan whilst extensive waiting lists exist. have asked for a meeting to be arranged with The Trust, once we have received additional information we have requested, s0 that we can have a more informed discussions regarding the next steps in addressing the issues identified. hope this addresses your concerns, please do not hesitate to contact me if vou require more information:
sent to me in a letter by (Director of Operations, MMHSCT) on the 23rd December 2014. In her lettel proposed the closure of the waiting list for complex cases from the 1s February 2015 until the 18 week referral to treatment pathway can be delivered by the Trust: was unable to support this proposal due to patient safety risks_ Following the National IAPT team review and the examination of the Psychological Therapies CQUIN that is in place relating to waiting times, Commissioners now have better understanding of how the manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are taken by the Trust to regularly cleanse and review the number of patients waiting: We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data. The Trust have indicated areas of significant pressure and that complex cases service are exceeding 'the available commissioned resource" Within the block contract in place there is no specific allocation for this service or any other Psychological Therapies, with the exception of IAPT, and so am unsure what the Trust considers 'the available commissioned resource' is_ We have recently made a request tol ((Director of Finance) at the Contracts Meeting with the Trust for information regarding the level of Psychological Therapy input into inpatient and community services to understand which services have input and which do not: As commissioners we do not have access to this information and although some existing service specifications detail psychological therapy input it has become evident that some services do not have the access we believed was available and we need a clear picture across the Trust services_ We have also asked for clarification the Trust as to why have identified Psychological Therapies within its Cost Improvement Programme (CIP) plan when there are such long waiting lists. For the past few years the Trust has identified significant contribution toward its CIP plan vacancies within the Psychological Therapy service budget and the letter from the Trust indicated that 'without additional investment the service does not have sufficient commissioned resource to address its historical waiting list and provide timely access to newly referred clients' have made it clear to Manchester Mental Health and Social Care Trust that do not support Psychological Therapies included within CIP plan whilst extensive waiting lists exist. have asked for a meeting to be arranged with The Trust, once we have received additional information we have requested, s0 that we can have a more informed discussions regarding the next steps in addressing the issues identified. hope this addresses your concerns, please do not hesitate to contact me if vou require more information:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
Report Sections
Investigation and Inquest
On the 10th April 2014 commenced an investigation into the death of Rowena Kathryn Golton, date of birth 26.02.1969_ The investigation concluded on the 15th August 2014 and the conclusion was one that the deceased had taken her own life_ The medical cause of death was 1a) Multiple Traumatic Injuries
Circumstances of the Death
The deceased had a history of recurring depression which became more pronounced from August 2013 onwards. She had attended at her GP surgery initially then in January 2014 had seen the mental health services recurring feature throughout her presentation was suicidal thinking: deceased had a period of inpatient admission and subsequent involvement of the crisis team: There was clear evidence that the deceased needed longer-term psychological therapy. A referral had been made but due to the length of the waiting list she had not been seen: On the 6" of April 2014 the deceased jumped from the fire escape at the top of Vernon Mill in Stockport: At the time of her death she was suffering from deterioration in her mental illness In the early hours of the 6" of April the deceased had presented at the A&E Department at Manchester Royal Infirmary having been brought back from abroad by her mother who had travelled to collect her following her admission to hospital in Morocco as a result of her mental illness She was assessed as a low risk of suicide and discharged with a plan for her to be seen later in the day on the 6th of April by the crisis team_ and and The
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.