Shahzadi Khan
PFD Report
All Responded
Ref: 2024-0046
All 1 response received
· Deadline: 27 Mar 2024
Response Status
Responses
1 of 1
56-Day Deadline
27 Mar 2024
All responses received
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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. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular: A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians. Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used. Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
2. There was evidence from her family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective.
3. The inquest heard that due to its size the mental health trust covers a number of areas. Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care. The inquest heard that this was compounded by a lack of awareness by the Trafford HBTT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers.
2. There was evidence from her family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective.
3. The inquest heard that due to its size the mental health trust covers a number of areas. Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care. The inquest heard that this was compounded by a lack of awareness by the Trafford HBTT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers.
Responses
DHSC reports a 74% reduction in out-of-area mental health placements due to a national strategy and local NHS Greater Manchester ICB efforts, which now manage all adult acute mental health patients within the region. They also provided funding to Mind in Greater Manchester for menopause awareness training and resources for healthcare staff.
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Dear Ms Mutch
Thank you for your Regulation 28 report to prevent future deaths dated 29 January 2024 about the death of Shahzadi Khan. I am replying as Minister with responsibility for Mental Health and Womens Strategy.
Firstly, I would like to say how saddened I was to read of the circumstances of Ms Khan’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please also accept my sincere apologies for the delay in responding to this matter.
The report raises the concerns about:
- how a how a shortage of mental health beds nationally can lead to patients being placed far from home, impacting their care and increasing risks. Key issues include families not being able to stay in contact or visit. Difficulties in communication and sharing information between patients, families, and clinicians, especially when non- NHS or out-of-trust beds were used. Additionally, out-of-area trusts and private providers lacked familiarity with local discharge support arrangements, resulting in less effective communication and coordination.
- The inquest heard that due to its size the mental health trust covers a number of areas. Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care. The inquest heard that this was compounded by a lack of awareness by the Trafford HBTT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers.
- There was evidence from Ms Khan’s family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective.
In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission.
To improve the issue of out of area placements, and to support adult social care and discharge, up to £2.8 billion has been made available in 2023/24 and £4.7 billion in 2024/25. This can be used to support discharge from mental health inpatient settings, reducing bed occupancy and OAPs. The Department has been working with NHS England and other
partners to develop statutory guidance for discharge from all mental health inpatient settings. This was published on 26 January 2024, setting out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. Private companies have always played a role in the NHS, and patients should expect a safe and good quality service regardless of whether their care is delivered by independent sector or public sector providers. All providers, whether independent or NHS, must register with the Care Quality Commission and follow a set of fundamental standards of safety and quality below which care should never fall.
We have also made specific enquiries at local level. Up until September 2022 Greater Manchester had very low numbers of reportable out of area placements. They then experienced a gradual increase. The management of contracted independent sector provision and out of area placements is managed by the North-West Bed Bureau. Following the increase in reportable out of area placements the capacity within the North-West Bed Bureau was strengthened. Practitioners were allocated to specific providers which enabled them to develop better relationships- within this was included in person visits to better understand the settings they were placing patients in. There were always strong processes in place for patients placed within Greater Manchester but in a different local authority to the one in which they resided. These processes and policies have been reviewed and strengthened to ensure the same rigor and oversight is in place for those patients who are placed outside of Greater Manchester. There is a weekly meeting at NHSGM ICB level (Multi Agency Discharge Event) about out of area placements ensuring that as an ICB, they have real grip and control. There is also a trajectory of improvement in place with their NHS Trusts to reduce the number of out of area placements
To raise awareness of menopause for healthcare staff including the effect of menopause on mental health, funding has been given to Mind in Greater Manchester (this is a partnership of five local Minds working together to ensure people experience better mental health and to support people with their mental health to live well and feel valued in their communities and at work). The funding will:
• Enable local Minds to provide free training to Small and Medium Enterprises (SME’s), that have less than 250 employees and may not have the funding to access such training, to raise awareness of menopause to both managers and colleagues
• Fund free mindfulness and relaxation for menopause courses. These courses support individuals in learning mindfulness and meditation to give them greater capacity to manage the emotional and physical impacts of menopause and to improve their mental health.
• Delivery of free, culturally appropriate and specific menopause awareness sessions in different communities across Greater Manchester delivering in a range of multicultural languages and providing in-depth understanding of symptoms and what help is accessible Greater Manchester has also provided a free access to menopause resource for anyone working in health and care in the city region. It is hoped that this course will help form part of a wider cultural change that leads to better support for people going through the menopause, whilst also helping individuals understand the challenges and how to get the right help.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Best Wishes,
MARIA CAULFIELD
Thank you for your Regulation 28 report to prevent future deaths dated 29 January 2024 about the death of Shahzadi Khan. I am replying as Minister with responsibility for Mental Health and Womens Strategy.
Firstly, I would like to say how saddened I was to read of the circumstances of Ms Khan’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please also accept my sincere apologies for the delay in responding to this matter.
The report raises the concerns about:
- how a how a shortage of mental health beds nationally can lead to patients being placed far from home, impacting their care and increasing risks. Key issues include families not being able to stay in contact or visit. Difficulties in communication and sharing information between patients, families, and clinicians, especially when non- NHS or out-of-trust beds were used. Additionally, out-of-area trusts and private providers lacked familiarity with local discharge support arrangements, resulting in less effective communication and coordination.
- The inquest heard that due to its size the mental health trust covers a number of areas. Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care. The inquest heard that this was compounded by a lack of awareness by the Trafford HBTT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers.
- There was evidence from Ms Khan’s family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective.
In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission.
To improve the issue of out of area placements, and to support adult social care and discharge, up to £2.8 billion has been made available in 2023/24 and £4.7 billion in 2024/25. This can be used to support discharge from mental health inpatient settings, reducing bed occupancy and OAPs. The Department has been working with NHS England and other
partners to develop statutory guidance for discharge from all mental health inpatient settings. This was published on 26 January 2024, setting out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. Private companies have always played a role in the NHS, and patients should expect a safe and good quality service regardless of whether their care is delivered by independent sector or public sector providers. All providers, whether independent or NHS, must register with the Care Quality Commission and follow a set of fundamental standards of safety and quality below which care should never fall.
We have also made specific enquiries at local level. Up until September 2022 Greater Manchester had very low numbers of reportable out of area placements. They then experienced a gradual increase. The management of contracted independent sector provision and out of area placements is managed by the North-West Bed Bureau. Following the increase in reportable out of area placements the capacity within the North-West Bed Bureau was strengthened. Practitioners were allocated to specific providers which enabled them to develop better relationships- within this was included in person visits to better understand the settings they were placing patients in. There were always strong processes in place for patients placed within Greater Manchester but in a different local authority to the one in which they resided. These processes and policies have been reviewed and strengthened to ensure the same rigor and oversight is in place for those patients who are placed outside of Greater Manchester. There is a weekly meeting at NHSGM ICB level (Multi Agency Discharge Event) about out of area placements ensuring that as an ICB, they have real grip and control. There is also a trajectory of improvement in place with their NHS Trusts to reduce the number of out of area placements
To raise awareness of menopause for healthcare staff including the effect of menopause on mental health, funding has been given to Mind in Greater Manchester (this is a partnership of five local Minds working together to ensure people experience better mental health and to support people with their mental health to live well and feel valued in their communities and at work). The funding will:
• Enable local Minds to provide free training to Small and Medium Enterprises (SME’s), that have less than 250 employees and may not have the funding to access such training, to raise awareness of menopause to both managers and colleagues
• Fund free mindfulness and relaxation for menopause courses. These courses support individuals in learning mindfulness and meditation to give them greater capacity to manage the emotional and physical impacts of menopause and to improve their mental health.
• Delivery of free, culturally appropriate and specific menopause awareness sessions in different communities across Greater Manchester delivering in a range of multicultural languages and providing in-depth understanding of symptoms and what help is accessible Greater Manchester has also provided a free access to menopause resource for anyone working in health and care in the city region. It is hoped that this course will help form part of a wider cultural change that leads to better support for people going through the menopause, whilst also helping individuals understand the challenges and how to get the right help.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Best Wishes,
MARIA CAULFIELD
Report Sections
Investigation and Inquest
On 15th February 2023 I commenced an investigation into the death of Shahzadi Khan. The investigation concluded on the 23rd November 2023 and the conclusion was one of Narrative: Suicide contributed to by a failure to effectively and appropriately manage her care in the community following discharge from hospital. The medical cause of death was 1a) Drug Toxicity.
Circumstances of the Death
On 29th December 2022, Shahzadi Khan was detained under section 2 of the Mental Health Act due to her mental state and the risks she presented. She was found to have had a manic episode with psychotic symptoms. Due to a lack of beds, she was placed in a privately-run mental health hospital in Norfolk. She remained there until her discharge to the family home on 26th January 2023. She was commenced on Olanzapine and Zopiclone for her mental health whilst an inpatient. Her diagnosis on discharge was mania with psychotic symptoms. She was to remain on olanzapine in the community. Her placement out of area contributed to disjointed and inadequate discharge planning to support her in the community and was exacerbated by poor communication between the team managing out of area placements and the local team. As a consequence, the aftercare planning did not take place in accordance with S117 Mental Health Act. This was exacerbated by a failure by all health professionals involved in her care within the mental health trust to recognise that she needed to be referred on to the Trafford Shared Care pathway. A referral would have ensured she received support and care for at least 12 weeks when she returned to the community. There is no clear reason for this failure.
She was seen by the Home-Based Treatment Team (HBTT) on 28th January and 2nd February, then discharged back to her GP. Within a week of that discharge from HBTT, which meant she had been left with no mental health support, she had deteriorated significantly. On 9th February her GP sent her to hospital for emergency assessment due to her presentation. She was discharged home to be seen by the Home-Based Treatment Team on 11th February. She was seen by that team on 11th, 12th, and 13th February.
There was still no recognition of the fact that the Trafford policy was not being followed. She had indicated her lack of compliance with olanzapine, suicidal thoughts and her behaviour on 13th February was erratic. On 14th February 203 she took a fatal overdose of prescribed zopiclone at her home address.
She was seen by the Home-Based Treatment Team (HBTT) on 28th January and 2nd February, then discharged back to her GP. Within a week of that discharge from HBTT, which meant she had been left with no mental health support, she had deteriorated significantly. On 9th February her GP sent her to hospital for emergency assessment due to her presentation. She was discharged home to be seen by the Home-Based Treatment Team on 11th February. She was seen by that team on 11th, 12th, and 13th February.
There was still no recognition of the fact that the Trafford policy was not being followed. She had indicated her lack of compliance with olanzapine, suicidal thoughts and her behaviour on 13th February was erratic. On 14th February 203 she took a fatal overdose of prescribed zopiclone at her home address.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.