David Jukes
PFD Report
All Responded
Ref: 2019-0329
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
All 5 responses received
· Deadline: 11 Sep 2019
Sent To
Response Status
Responses
5 of 5
56-Day Deadline
11 Sep 2019
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. The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody. She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threated suicide and harm to others and not come out in response to police negotiators. This information was not included in a verbal handover according to the nurse’s evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest.
2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of the previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred. Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise. If reliable information is not being passed there is a risk to life from ill-informed decision making.
3. Despite not being informed by the BCPFT liaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest, further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team. It is not known why this was. Not having a robust and effective system to carry out necessary assessments whilst a patient is detained in police custody puts lives at risk.
4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the 2nd October 2018 the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance. There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before. Failure to utilise all means of locating a patient whose whereabouts are unknown, who requires assessment and who is not making contact with the team puts lives at risk.
5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he was discussed or a plan made to locate and assess him. No explanation was provided in evidence nor was evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at risk.
6. On the 9th October 2018 a HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018. By this time there was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact. The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk. No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues.
7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes. Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment. There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians maybe mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and that this noncompliance will go undetected.
8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from a combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team. Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments. If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk.
2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of the previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred. Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise. If reliable information is not being passed there is a risk to life from ill-informed decision making.
3. Despite not being informed by the BCPFT liaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest, further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team. It is not known why this was. Not having a robust and effective system to carry out necessary assessments whilst a patient is detained in police custody puts lives at risk.
4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the 2nd October 2018 the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance. There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before. Failure to utilise all means of locating a patient whose whereabouts are unknown, who requires assessment and who is not making contact with the team puts lives at risk.
5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he was discussed or a plan made to locate and assess him. No explanation was provided in evidence nor was evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at risk.
6. On the 9th October 2018 a HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018. By this time there was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact. The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk. No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues.
7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes. Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment. There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians maybe mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and that this noncompliance will go undetected.
8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from a combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team. Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments. If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk.
Responses
Response received
View full response
Dear Ms Brown,
Re: Regulation 28 Report to Prevent Future Deaths – David Jonothan Jukes (09/10/2018)
Thank you for your Regulation 28 Report dated 12 July 2019 concerning the death of David Jonothan Jukes on 09 October 2018.
I was very saddened to read of the circumstances surrounding Mr Jukes’s death and would like to extend my condolences to his family and loved ones during this very difficult time.
Please note this response will address the matters of concern from a national level and we would expect the local NHS agencies, which I note are copied in to the letter, to address the local concerns raised.
Sufficient information regarding arrests was not provided to liaison and diversion practitioner:
NHS England and NHS Improvement will work with police forces to ensure that all relevant information from a police perspective is given to the liaison and diversion practitioner, including the nature of the detained person’s presentation at the point of arrest, if relevant.
We will commit to a national event by the end of March 2020 to debrief on this matter and any other information sharing/exchange issues that have been raised in other reports. We will invite liaison and diversion practitioners as well as NHS Commissioners and police representatives in order to share lessons learnt. Additionally, there has been work to address this concern at a regional level:
Ms Emma Brown Area Coroner for Birmingham and Solihull The Coroner's Court 50 Newton Street Birmingham B4 6NE
National Medical Directorate NHS England and NHS Improvement Skipton House 80 London Road LONDON SE1 6LH
Telephone:
Email:
20th September 2019
OFFICIAL High quality care for all, now and for future generations
• NHS England and NHS Improvement has been working with West Midland Police regarding their new IT system (‘Connect’) which the police are implementing in the summer 2020
• Connect will be available in custody
• As part of its development NHS England and NHS Improvement has supported the three liaison and diversion teams (Coventry, Black Country and Birmingham) who will collaborate with West Midlands Police on a specific liaison and diversion section
• Once implemented, liaison and diversion teams and police colleagues will have increased access to immediate and relevant information. It is envisaged that this will not only improve the safety of individuals being managed but also add quality to the referral/identification and priority of those coming into custody.
• All three liaison and diversion teams will have access to partitioned parts of the police system that helps them understand the context of the persons arrival into custody and more information about historical custody appearances.
• All liaison and diversion teams have had information sharing training and this training offer has also been made to Police Healthcare providers
There was a lack of communication between different mental health trusts:
The NHS Long Term Plan is committed to ensuring that by 2024, secondary care providers in England, including acute, community and mental health care settings, will be fully digitised, including clinical and operational processes across all settings, locations and departments. Data will be captured, stored and transmitted electronically, supported by robust IT infrastructure and cyber security, and Local Health and Care Records will cover the whole country.
As part of this, a number of steps are being taken, led by NHS England /Improvement and NHSX, to enable the safe and secure sharing of digital records. NHSX brings together teams from the Department of Health and Social Care, and NHS England and NHS Improvement to drive digital transformation and lead policy, implementation and change. The Local Integrated Health and Care Records programme, led by NHSX, will provide strategic vision for safely and securely sharing data across different NHS and partner organisations. The aim of the programme is to create an information sharing environment that helps our health and care services to continually improve the care that we deliver. This includes ensuring that health and care professionals have access to a comprehensive care record with the information they need to inform their care decisions, when and where they need it. As well as empowering people to look after themselves better and make informed choices about their own health and care and being able to analyse the data to enable more precise and actionable interventions and support the development of population health management. NHS England is also working with the mental health Global Digital Exemplar programmes to develop a range of basic and more
OFFICIAL High quality care for all, now and for future generations advanced tools to support decisions on care across the pathway, this includes the identification of need, detection of risk and the application of best practice.
In parallel to this, NHS England and NHS Improvement and NHS X are working to improve the availability of mental health information and evidence-based resources online, this includes local crisis service directories.
Additionally, the national service specification for liaison and diversion services clearly outlines expectations relating to providers’ IT systems. NHS England and NHS Improvement are updating N3 connections to Health and Social Care Network (HSCN) connections to ensure that liaison and diversion providers can access relevant health information including Summary Care Records. HSCN has been procured in 101 police custody suites, and 84 courts and the rollout of this procurement will commence in early 2020.
NHS England and Improvement will produce an information sharing protocol for the NHS and Independent sector Mental Health Trusts that are co-commissioned with the local NHS Clinical Commissioning Groups (CCGs) to deliver services to the Armed Forces. This will ensure that patient information can be shared thereby providing a comprehensive and simultaneous patient record. This protocol will be in place and operational by 1 April 2020. Where NHS England and NHS Improvement Armed Forces co-commission mental health services with CCGs we will strengthen the commissioning relationships already in place and work through an integrated approach to ensure that the appropriate Quality and Safety systems are in place to identify risk and have mechanisms to respond. NHS England and NHS Improvement Quality and Safety meetings are currently held with the providers only. We recognise the importance of integrated commissioning and, working with our local CCGs, will ensure that from April 2020 the meetings held with providers of services both the relevant CCG and NHS England commissioners will be invited to attend.
NHS England and NHS Improvement recognise that quality assurance plays a vital role in ensuring patients receive high quality, safe care and therefore intends to further strengthen the Quality Assurance role within a dedicated Armed Forces Quality and Safety Manager. This role will have the responsibility of involvement and oversight of reviews and assurance processes liaising with internal and external stakeholders. The post has been built into the new Operating Model for NHS England and NHS Improvement and we will look to appoint to this position over the next few months in line with the organisational transition programme
Resourcing levels in the HTT team:
You raised a significant concern that a lack of sufficient capacity within the Birmingham and Solihull Mental Health Foundation Trust (BSMHT) Home Treatment Team was resulting in staff being unable to fulfil their professional obligations to their patients. This includes maintaining good record keeping which is critical to patient safety, particularly to support people who come into contact with other parts of the system, including the emergency services.
Ensuring that all areas have sufficient resource to deliver the core functions of a Home Treatment Team 24/7 is a key national commitment, first established in the
OFFICIAL High quality care for all, now and for future generations publication of the Five Year Forward View for Mental Health and then reiterated in the Long Term Plan (LTP) for the NHS earlier this year. Nationally, it is expected that the whole country will have met this ambition by the end of March 2021, resulting in full coverage by 24/7 teams which have the capacity to be highly responsive and to offer genuinely intensive support as an alternative to hospital.
To support the delivery of this ambition, NHS England and Improvement have made significant new funding available (in addition to funding already allocated to CCGs since 2016) over the next two years via uplifts to local CCG baselines and through the targeted allocation of additional centrally held transformation funds. We have just finished the process of allocating the centrally held funding, which will be released to Sustainability and Transformation Partnerships (STPs) on a quarterly basis. Overall the additional funding available nationally in 2019/20 and 2020/21, primarily intended for ensuring 24/7 coverage of crisis resolution and intensive home treatment (CRHT) functions, is £80m and £140m respectively. More information on the funding profile is available in the Mental Health Implementation Plan for the NHS Long Term Plan. The transformation funding has been allocated on a ‘fair shares’ basis and awarded following the submission of local proposals that demonstrated how each STP will deliver the ambition of 24/7, properly resourced CRHT functions across their population. Over the next two years we will be assuring the use of this dedicated funding to ensure progress towards the 2021 ambition.
We are aware that Birmingham and Solihull Mental Health Trust are experiencing capacity constraints across their crisis and acute mental healthcare pathway, and they have identified a number of areas for improvement which they are working to address. We have provided some direct support to the trust in the form of clinically- led sessions focussed on effective crisis response and acute pathway capacity management. They are also part of a small group of STPs nationally which are subject to a more in-depth assurance process related to their progress against the ambition to reduce acute out of area placements. As high out of area placements are another indicator of broader capacity pressures across a crisis and acute mental health system, this assurance process will include a particular focus on the effective use of transformation funding to ensure that local CRHT functions are delivered in line with the evidence base. Further, noting the report’s similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4th October 2018 regarding system capacity, we will use our direct contact with the Trust and STP over the coming months to explore and address relevant patient safety concerns, involving clinical expertise in both executive level discussions and an implementation support workshop focussed on transforming the crisis pathway.
Your report acknowledged that at the time of the inquest there was evidence of work already underway to improve the local HTTs capacity, including introducing a system to prevent inappropriate referrals and the funding of further two CPNS for HTTs within BSMHT. However, you also noted concerns that these changes were not sufficient to ensure lives are not put at risk in future. The new funding (described above) committed via the NHS LTP for crisis resolution and home treatment teams alone is significant and should enable the further expansion required in BSMHT’s HTT to ensure it is operating effectively and safely. It is important to note that this funding is just one small portion of a large increase in investment in crisis, acute and community services for adult with severe mental illness (SMI) profiled over the next 5
OFFICIAL High quality care for all, now and for future generations years. This wider system funding will be critical in helping all areas to rebalance their provision, ensuring more people can be treated effectively in the community and enabling demand to be met safely and sustainably.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – David Jonothan Jukes (09/10/2018)
Thank you for your Regulation 28 Report dated 12 July 2019 concerning the death of David Jonothan Jukes on 09 October 2018.
I was very saddened to read of the circumstances surrounding Mr Jukes’s death and would like to extend my condolences to his family and loved ones during this very difficult time.
Please note this response will address the matters of concern from a national level and we would expect the local NHS agencies, which I note are copied in to the letter, to address the local concerns raised.
Sufficient information regarding arrests was not provided to liaison and diversion practitioner:
NHS England and NHS Improvement will work with police forces to ensure that all relevant information from a police perspective is given to the liaison and diversion practitioner, including the nature of the detained person’s presentation at the point of arrest, if relevant.
We will commit to a national event by the end of March 2020 to debrief on this matter and any other information sharing/exchange issues that have been raised in other reports. We will invite liaison and diversion practitioners as well as NHS Commissioners and police representatives in order to share lessons learnt. Additionally, there has been work to address this concern at a regional level:
Ms Emma Brown Area Coroner for Birmingham and Solihull The Coroner's Court 50 Newton Street Birmingham B4 6NE
National Medical Directorate NHS England and NHS Improvement Skipton House 80 London Road LONDON SE1 6LH
Telephone:
Email:
20th September 2019
OFFICIAL High quality care for all, now and for future generations
• NHS England and NHS Improvement has been working with West Midland Police regarding their new IT system (‘Connect’) which the police are implementing in the summer 2020
• Connect will be available in custody
• As part of its development NHS England and NHS Improvement has supported the three liaison and diversion teams (Coventry, Black Country and Birmingham) who will collaborate with West Midlands Police on a specific liaison and diversion section
• Once implemented, liaison and diversion teams and police colleagues will have increased access to immediate and relevant information. It is envisaged that this will not only improve the safety of individuals being managed but also add quality to the referral/identification and priority of those coming into custody.
• All three liaison and diversion teams will have access to partitioned parts of the police system that helps them understand the context of the persons arrival into custody and more information about historical custody appearances.
• All liaison and diversion teams have had information sharing training and this training offer has also been made to Police Healthcare providers
There was a lack of communication between different mental health trusts:
The NHS Long Term Plan is committed to ensuring that by 2024, secondary care providers in England, including acute, community and mental health care settings, will be fully digitised, including clinical and operational processes across all settings, locations and departments. Data will be captured, stored and transmitted electronically, supported by robust IT infrastructure and cyber security, and Local Health and Care Records will cover the whole country.
As part of this, a number of steps are being taken, led by NHS England /Improvement and NHSX, to enable the safe and secure sharing of digital records. NHSX brings together teams from the Department of Health and Social Care, and NHS England and NHS Improvement to drive digital transformation and lead policy, implementation and change. The Local Integrated Health and Care Records programme, led by NHSX, will provide strategic vision for safely and securely sharing data across different NHS and partner organisations. The aim of the programme is to create an information sharing environment that helps our health and care services to continually improve the care that we deliver. This includes ensuring that health and care professionals have access to a comprehensive care record with the information they need to inform their care decisions, when and where they need it. As well as empowering people to look after themselves better and make informed choices about their own health and care and being able to analyse the data to enable more precise and actionable interventions and support the development of population health management. NHS England is also working with the mental health Global Digital Exemplar programmes to develop a range of basic and more
OFFICIAL High quality care for all, now and for future generations advanced tools to support decisions on care across the pathway, this includes the identification of need, detection of risk and the application of best practice.
In parallel to this, NHS England and NHS Improvement and NHS X are working to improve the availability of mental health information and evidence-based resources online, this includes local crisis service directories.
Additionally, the national service specification for liaison and diversion services clearly outlines expectations relating to providers’ IT systems. NHS England and NHS Improvement are updating N3 connections to Health and Social Care Network (HSCN) connections to ensure that liaison and diversion providers can access relevant health information including Summary Care Records. HSCN has been procured in 101 police custody suites, and 84 courts and the rollout of this procurement will commence in early 2020.
NHS England and Improvement will produce an information sharing protocol for the NHS and Independent sector Mental Health Trusts that are co-commissioned with the local NHS Clinical Commissioning Groups (CCGs) to deliver services to the Armed Forces. This will ensure that patient information can be shared thereby providing a comprehensive and simultaneous patient record. This protocol will be in place and operational by 1 April 2020. Where NHS England and NHS Improvement Armed Forces co-commission mental health services with CCGs we will strengthen the commissioning relationships already in place and work through an integrated approach to ensure that the appropriate Quality and Safety systems are in place to identify risk and have mechanisms to respond. NHS England and NHS Improvement Quality and Safety meetings are currently held with the providers only. We recognise the importance of integrated commissioning and, working with our local CCGs, will ensure that from April 2020 the meetings held with providers of services both the relevant CCG and NHS England commissioners will be invited to attend.
NHS England and NHS Improvement recognise that quality assurance plays a vital role in ensuring patients receive high quality, safe care and therefore intends to further strengthen the Quality Assurance role within a dedicated Armed Forces Quality and Safety Manager. This role will have the responsibility of involvement and oversight of reviews and assurance processes liaising with internal and external stakeholders. The post has been built into the new Operating Model for NHS England and NHS Improvement and we will look to appoint to this position over the next few months in line with the organisational transition programme
Resourcing levels in the HTT team:
You raised a significant concern that a lack of sufficient capacity within the Birmingham and Solihull Mental Health Foundation Trust (BSMHT) Home Treatment Team was resulting in staff being unable to fulfil their professional obligations to their patients. This includes maintaining good record keeping which is critical to patient safety, particularly to support people who come into contact with other parts of the system, including the emergency services.
Ensuring that all areas have sufficient resource to deliver the core functions of a Home Treatment Team 24/7 is a key national commitment, first established in the
OFFICIAL High quality care for all, now and for future generations publication of the Five Year Forward View for Mental Health and then reiterated in the Long Term Plan (LTP) for the NHS earlier this year. Nationally, it is expected that the whole country will have met this ambition by the end of March 2021, resulting in full coverage by 24/7 teams which have the capacity to be highly responsive and to offer genuinely intensive support as an alternative to hospital.
To support the delivery of this ambition, NHS England and Improvement have made significant new funding available (in addition to funding already allocated to CCGs since 2016) over the next two years via uplifts to local CCG baselines and through the targeted allocation of additional centrally held transformation funds. We have just finished the process of allocating the centrally held funding, which will be released to Sustainability and Transformation Partnerships (STPs) on a quarterly basis. Overall the additional funding available nationally in 2019/20 and 2020/21, primarily intended for ensuring 24/7 coverage of crisis resolution and intensive home treatment (CRHT) functions, is £80m and £140m respectively. More information on the funding profile is available in the Mental Health Implementation Plan for the NHS Long Term Plan. The transformation funding has been allocated on a ‘fair shares’ basis and awarded following the submission of local proposals that demonstrated how each STP will deliver the ambition of 24/7, properly resourced CRHT functions across their population. Over the next two years we will be assuring the use of this dedicated funding to ensure progress towards the 2021 ambition.
We are aware that Birmingham and Solihull Mental Health Trust are experiencing capacity constraints across their crisis and acute mental healthcare pathway, and they have identified a number of areas for improvement which they are working to address. We have provided some direct support to the trust in the form of clinically- led sessions focussed on effective crisis response and acute pathway capacity management. They are also part of a small group of STPs nationally which are subject to a more in-depth assurance process related to their progress against the ambition to reduce acute out of area placements. As high out of area placements are another indicator of broader capacity pressures across a crisis and acute mental health system, this assurance process will include a particular focus on the effective use of transformation funding to ensure that local CRHT functions are delivered in line with the evidence base. Further, noting the report’s similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4th October 2018 regarding system capacity, we will use our direct contact with the Trust and STP over the coming months to explore and address relevant patient safety concerns, involving clinical expertise in both executive level discussions and an implementation support workshop focussed on transforming the crisis pathway.
Your report acknowledged that at the time of the inquest there was evidence of work already underway to improve the local HTTs capacity, including introducing a system to prevent inappropriate referrals and the funding of further two CPNS for HTTs within BSMHT. However, you also noted concerns that these changes were not sufficient to ensure lives are not put at risk in future. The new funding (described above) committed via the NHS LTP for crisis resolution and home treatment teams alone is significant and should enable the further expansion required in BSMHT’s HTT to ensure it is operating effectively and safely. It is important to note that this funding is just one small portion of a large increase in investment in crisis, acute and community services for adult with severe mental illness (SMI) profiled over the next 5
OFFICIAL High quality care for all, now and for future generations years. This wider system funding will be critical in helping all areas to rebalance their provision, ensuring more people can be treated effectively in the community and enabling demand to be met safely and sustainably.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Response received
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Dear Sirs_ David Jonothan Jukes Deceased DOD: 09/10/2018 Response to Regulation 28 Report We write in respect of the Regulation 28 report dated 26th July 2019 arising from the death of Dave Jukes: Please accept this as the response provided on behalf of West Midlands Police. In your report; you set out your concerns as follows: The psychiatric Iiaison and diversion practitioner employed by BCPFT who attended to review Mr: Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody: She was provided with a printout of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft;, threated suicide and harm to others and not come out in response to police negotiators This information was not included in a verbal handover according to the nurse's evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage Please reply to: Staffordshire Office Birmingham Office: Joint Legal Services Joint Legal Services Staffordshire Police Headquarters West Midlands Police PO Box 3167 Lloyd House, Colmore Circus Stafford, ST16 9JZ Birmingham B4 6NQ Tel: 01785 232259 Tel: 0121 626 8317 Fax: 0121 626 8272 Please be aware that all information provided to Staffordshire ad West Midlands Police Joint Legal Services will be held a treated in confidence accordance with the Data Protection Act 2018, It may be shared with other Force departments or third party organisations including- but not limited t0p external solicitors Counsel and, in relation t0 claims handling, Insurers: Personal infommation may also be used for statistical purposes for fraud and crime prevention and may be checked withldisclosed to regulatory bodies: The information provided may be held electronically andlor in paper form and will be secure at all times: Please be aware that your personal data will be processed for the perfonance of tasks canied in the public interest 0r in the exercise of the Police's official authonty, and t0 comply with legal obligations: "Calls may be monitored andlor recorded for security, quality control or training purposes_ Regulated by the Solicitors Regulatory Authority WE DO NOT ACCEPT SERVICE OF DOCUMENTS BY EMAIL OR FAX L14002183/J5 00192590 Ond kept out .
with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest The key issue appears to be what information is providedlavailable to the Liaison and Diversion team in custody: In order to assess that; it is important to consider what information is recorded on the custody record in the first place. The arrest circumstances in this case are unusual, and fact specific. The relevant arrest circumstances related to the attendance of police officers the night before Mr. Jukes was presented at the custody suite_ The arresting officers were not the same officers as those who had attended the night before and as such did not have first-hand knowledge of the circumstances_ The arresting officer in this matter no longer works for the force and as such it is not possible to ascertain the extent of their knowledge The arrest package provided to the arresting officer which would have been provided to them to arrest cannot be located and may have destroyed due to the passage of time_ When Mr: Jukes was booked into custody, the arresting officer provided the information relating to the arrest that day, which is what appears on the custody record. The officer wouldnt have told the Custody Sgt the history of the detainee, but more what he has come into custody for as this is relevant for the purposes of the authorisation of detention: In Mr Jukes' case, the circumstances of his contact with the police on the 27th September were relevant to the circumstances of his arrest the next day. However, that will not necessarily be the case for every individual who has contact with the police shortly before are arrested_ It is not reasonable or practicable to prescribe exactly what must be said about the circumstances of an arrest when an individual is being detained; officers are expected to use their professional judgement about what information is provided to custody sergeants about the material circumstances of an arrest This will often be encompassed within the circumstances of the arrest itself, depending on that particular case_ It would be expected that the arresting officer prior to entering the custody suite would have considered the detainee prompt card (a copy of which is attached to this letter) and brought to the attention anything of relevance to the custody sergeant: Whether further information should have been recorded on the custody record in this case was not explored at all in the course of the inquest, and quite properly does not feature in the Regulation 28 report. The referral process is that the officers provide the Liaison and Diversion Team with a risk assessment form (a copy of such form is attached) and a copy of the custody front sheet: There is nothing further required by the Liaison and Diversion team for a referral. This process is more onerous than the original input given to custody staff which states that all that is required is verbal referral and note in the custody record is all that is needed. copy of this PowerPoint is attached_ Whilst there was no specific reference to the incident the night previous there was evidence on the custody record that Mr Juke presented a risk to others and made threats of self-harm_ JS / L14002183 00192590 Page 2 prior they
Mr Jukes had been referred to Liaison and Diversion due to veteran, suffering from PTSD, and had suicidal and self-harm warning on his custody record. This can be seen at 28/9/18 at 17:43 hours. The custody record makes it clear that the statutory reason for arrest amongst other reasons was to "Prevent the person in question suffering physical injury" Furthermore the custody record states the following information: 28/9/18 10.44 PNC Notes changed for Warning signal Suicidal to States has SU thoughts every day 28/9/18 10.44 PNC notes changed for Warning Signal mental to MN PTSD and depression 28/9/18 10.45 Warning Signal Violent added with ONC notes threatened to kill officer to arrest. At 28/9/18 at 15.02 the record states "PIC has threatened has stated that if he is hurt in the process of his fingerprint taken he will kill. Therefore it is submitted that some information was readily available on the custody record. The Liaison and Diversion team can make verbal requests for further information. This would include access to the full custody record which is available in custody and would extend to call out logs and crime investigation logs that can be obtained by the custody staff: It would however be unlikely to extend to intelligence_ It is submitted that it is not for the police officers within custody to anticipate what else a liaison and Diversion practitioner might require in addition to the custody record and there is a reasonable expectation that practitioner will engage with the custody staff and request information when it is needed, depending on the circumstances of a particular individual. It is our position that there is an adequate system in place which ensures that the circumstances of an arrest are accurately recorded on the custody record and that a Liaison and Diversion practitioner has access to a wide range of information within the custody setting: Therefore, it is submitted that there is no risk of future death to be addressed and no action is required in this case_
with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest The key issue appears to be what information is providedlavailable to the Liaison and Diversion team in custody: In order to assess that; it is important to consider what information is recorded on the custody record in the first place. The arrest circumstances in this case are unusual, and fact specific. The relevant arrest circumstances related to the attendance of police officers the night before Mr. Jukes was presented at the custody suite_ The arresting officers were not the same officers as those who had attended the night before and as such did not have first-hand knowledge of the circumstances_ The arresting officer in this matter no longer works for the force and as such it is not possible to ascertain the extent of their knowledge The arrest package provided to the arresting officer which would have been provided to them to arrest cannot be located and may have destroyed due to the passage of time_ When Mr: Jukes was booked into custody, the arresting officer provided the information relating to the arrest that day, which is what appears on the custody record. The officer wouldnt have told the Custody Sgt the history of the detainee, but more what he has come into custody for as this is relevant for the purposes of the authorisation of detention: In Mr Jukes' case, the circumstances of his contact with the police on the 27th September were relevant to the circumstances of his arrest the next day. However, that will not necessarily be the case for every individual who has contact with the police shortly before are arrested_ It is not reasonable or practicable to prescribe exactly what must be said about the circumstances of an arrest when an individual is being detained; officers are expected to use their professional judgement about what information is provided to custody sergeants about the material circumstances of an arrest This will often be encompassed within the circumstances of the arrest itself, depending on that particular case_ It would be expected that the arresting officer prior to entering the custody suite would have considered the detainee prompt card (a copy of which is attached to this letter) and brought to the attention anything of relevance to the custody sergeant: Whether further information should have been recorded on the custody record in this case was not explored at all in the course of the inquest, and quite properly does not feature in the Regulation 28 report. The referral process is that the officers provide the Liaison and Diversion Team with a risk assessment form (a copy of such form is attached) and a copy of the custody front sheet: There is nothing further required by the Liaison and Diversion team for a referral. This process is more onerous than the original input given to custody staff which states that all that is required is verbal referral and note in the custody record is all that is needed. copy of this PowerPoint is attached_ Whilst there was no specific reference to the incident the night previous there was evidence on the custody record that Mr Juke presented a risk to others and made threats of self-harm_ JS / L14002183 00192590 Page 2 prior they
Mr Jukes had been referred to Liaison and Diversion due to veteran, suffering from PTSD, and had suicidal and self-harm warning on his custody record. This can be seen at 28/9/18 at 17:43 hours. The custody record makes it clear that the statutory reason for arrest amongst other reasons was to "Prevent the person in question suffering physical injury" Furthermore the custody record states the following information: 28/9/18 10.44 PNC Notes changed for Warning signal Suicidal to States has SU thoughts every day 28/9/18 10.44 PNC notes changed for Warning Signal mental to MN PTSD and depression 28/9/18 10.45 Warning Signal Violent added with ONC notes threatened to kill officer to arrest. At 28/9/18 at 15.02 the record states "PIC has threatened has stated that if he is hurt in the process of his fingerprint taken he will kill. Therefore it is submitted that some information was readily available on the custody record. The Liaison and Diversion team can make verbal requests for further information. This would include access to the full custody record which is available in custody and would extend to call out logs and crime investigation logs that can be obtained by the custody staff: It would however be unlikely to extend to intelligence_ It is submitted that it is not for the police officers within custody to anticipate what else a liaison and Diversion practitioner might require in addition to the custody record and there is a reasonable expectation that practitioner will engage with the custody staff and request information when it is needed, depending on the circumstances of a particular individual. It is our position that there is an adequate system in place which ensures that the circumstances of an arrest are accurately recorded on the custody record and that a Liaison and Diversion practitioner has access to a wide range of information within the custody setting: Therefore, it is submitted that there is no risk of future death to be addressed and no action is required in this case_
Response received
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Dear Ms Brown Re: Regulation 28 report; prevention of future death pertaining to Mr David Jukes, deceased May I open this letter by reiterating on behalf of Birmingham and Solihull Mental Health NHS Foundation Trust our most sincere condolences to Mrs Jukes following the sad death of her husband Mr David Jukes whilst he was under the care of our Trust We would also like to extend our thanks to Mrs Jukes for her participation in our serious incident investigation at a time that must have been extremely distressing for her and take this opportunity to extend an apology to Mrs Jukes once again for any failings that occurred whilst David was within our care_ On 15 October 2018 you commenced an investigation into the death of David Jonothan Jukes. The investigation concluded at the end of an inquest on 11th July 2019. The conclusion of the inquest was Mr. Jukes' death was a result of suicide. Despite being open to Home Treatment Team ('HTT') and the Complex Treatment Service (CTS') within Birmingham and Solihull Mental Health Trust (BSMHT') Mr. Jukes had not undergone an adequate assessment of his mental health by the time of his death as a result of the following: 1 At the time of attendance by the Liaison and Diversion practitioner at Oldbury custody suite on the 28th September 2018,the practitioner did not have full details of the events during the evening of the 27th into 28th from West Midlands Police nor access to records pertaining to his mental health held by his GP, the West Midlands Transition; Intervention and Liaison Service and BSMHT. With access to this information, she would have requested a Mental Health Act Assessment. Chair; Sue Davis, CBE Chief Executive: Roisin Fallon-Williams Idisability] Stonewall Customer Relations Mon Fri, 8am 6pm Tel: 0800 953 0045 Text: 07985 883 509 confident DWVERSITY Email: bsmhftcustomerrelations@nhs net Website: www bsmhft nhs uk EMPLOYER
2. Psychiatrist did not attend to assess Mr. Jukes whilst he was in custody on 28th September 2019 contrary to normal HTT practice.
3. Clinicians within HTT did not make adequate attempts to locate and engage with Mr. Jukes after being made aware of the events of the 27th and 28th September 2018 and after it was reported that he was threatening harm to others and to himself in conversation with a psychologist on the Znd October 2018. 4_ Clinicians within HTT did not make adequate attempts to locate and engage with Mr. Jukes after he failed to attend for medical review on the Ath October 2018,;
5. Clinicians within HTT did not offer Mr. Jukes' an urgent medical review when spoke to him on the morning of the 9th October 2018_ Following a post mortem the medical cause of death was determined to be: 1a) Hanging During the course of the inquest the evidence revealed matters giving rise to concern in such way that there is a risk that future deaths will occur unless action is taken The matters of concern are as follows_ 1 The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr: Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody. She was provided with a out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft;, threated suicide and harm to others and not come out in We understand that the Black Country Partnership NHS Foundation Trust are responding to you on this matter of concern: 2 The above psychiatric Iiaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT Iiaison and diversion team based at Barr custody suite and was informed that Mr. Jukes was not known to the service She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of the previous evening; It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred , Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn't explain why the nurse was left with the impression that he was not known to services_ It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise. If reliable information is not being passed there is a risk to life from ill-informed decision making: It is difficult for us to comment on this particular finding of the PFD as the liaison nurse remains unclear of who she spoke to or which service she contacted_ Nor is there any documented record of this contact within the Liaison and Diversion Service. Within our bed management service we have an arrangement for the identification for patients under our care. We do however recognise that if it were bed management that the nurse contacted, the existing arrangement failed to identify Mr Jukes We are therefore implementing a they print Perry
documented and recognised system within our bed management team for all such calls which includes phonetic spelling and other controls to ensure a consistent approach to this matter
3. Despite not being informed by the BCPFT Iiaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes: Despite this_ no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team: It is not known why this was. Not having a robust and effective system to out necessary assessments whilst a patient is detained in police custody lives at risk We are grateful to you for raising this matter with us as it has identified the need for a joint operating protocol to be developed between BSHMFT and the Liaison and Diversion Service in Sandwell We have been in liaison with this team and are scheduled to meet and develop this protocol in late September 2019.
4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the Znd October 2018 the HTT's only recorded attempt to contact Mr: Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife's phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance. There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before_ Failure to utilise all means of locating a patient whose whereabouts are unknown, who requires assessment and who is not making contact with the team lives at risk; We sincerely apologise for this matter: The matter of communication preferences is being addressed by the Trust in that we now have communication preference field within the clinical record RIO.
5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the Znd. There is no credible evidence he was discussed or a plan made to locate and assess him. No explanation was provided in evidence nor was evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at risk As you state, it is vitally important that clinical records are documented to evidence the care and treatment plans for patients that are discussed between clinicians. We have identified that when our Multi-Disciplinary Team meetings take place there is evidence of some inconsistency in the recording of discussions and outcomes in some areas In direct response to this finding we have increased administrative resources within our Home Treatment Teams to enable consistent administrative support to our Multi-Disciplinary Team meetings which in turn will ensure that outcomes are clearly recorded: In addition, we have commenced a Quality Improvement Project to develop clear standards for Multi- carry puts puts
Disciplinary Team meetings and recording requirements_ We apologise sincerely for this failing in our clinical record keeping for Mr Jukes_ 6 On the 9th October 2018 a HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass Were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018. By this time there was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances; had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact: The staff involved maintained in evidence that acted appropriately; evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk: No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues. In direct response to this matter of concern we are now reviewing our Home Treatment Team Operating Protocol to strengthen the requirement for nurse led triage and assessment screening and appropriate clinical escalation to a Consultant Psychiatrist Consultant Psychiatrist overview and scrutiny of each case would either be through direct clinical assessment or review or through input and direction within the multi-disciplinary team or through formal or informal supervision of doctors and other home treatment staff, We note the view of the team that they felt acted appropriately and are therefore also this sad incident as a Case Study in our new Clinical Risk Assessment and Management Training so that staff are fully alert to accumulative risk factors. This training is mandatory for all clinical staff in the Trust irrelevant of clinical profession or team. The first pilot of the new training model which also incorporates suicide prevention training is due to launch at the end of September 2019. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr: Jukes that was not recorded in his BSMHT RIO notes_ Furthermore, his Risk Screen was not updated after information came to HTT's attention that affected his risk assessment_ There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians maybe misled or iIl-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a message' 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to proper records and that this noncompliance will go undetected: they they using very they Key keep
We recognise the need for an improvement in clinical record keeping standards and how this is absolutely central to the effective care of our patients. We apologise that this was not evident within the case of Mr Jukes and are sincerely sorry for this failing: The importance of risk identification, formulation and recording forms a central part of our new Clinical Risk Assessment and Management Training which , as stated above, will be piloted from September 2019. In addition to this training, all staff irrelevant of discipline are required to undertaken annual training on information governance where the importance of clinical record keeping standards is also highlighted. We are conscious that our Home Treatment Teams have been operating within an environment of high demand and acuity and that this may at times compromise their ability to consistently meet the important standards that we expect of staff, We are investing a significant amount of new financial resource into our Home Treatment Team to increase workforce capacity _ This includes:
5.0 Full time Home Treatment Team Managers 2 positions have now been recruited to and a further 3 are currently out to advert 3 Full time Out of Hours Practitioners all posts are currently out to advert
5.0 Full time Additional Medical Middle Grades An additional 0.SWTE Psychologist in every Home treatment Team (currently out to advert) 4 full time Administrative posts to support Home Treatment Team activity and recording of MDT discussions In addition to this, we have launched two critical Quality Improvement Projects one is to develop and implement core MDT minimum standards for recording of clinical documentation; the second is to improve our care planning and clinical risk assessment processes_
8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team_ Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk Please see the actions that we are taking in relation to an increase in resources to all Home Treatment Teams alongside the Quality improvement Projects that are being taken forward to ensure that key aspects of record keeping are as effective streamlined as possible so that we are able to reduce duplicative entries for staff on the RIO record. In closing this response, we would like to assure you that we have taken the matters raised in your Regulation 28 report extremely seriously and once again apologise to Mrs Jukes: We hope that the above actions will make a difference to the experience of future patients in our care and thank you for formally raising these with our organisation. yet
2. Psychiatrist did not attend to assess Mr. Jukes whilst he was in custody on 28th September 2019 contrary to normal HTT practice.
3. Clinicians within HTT did not make adequate attempts to locate and engage with Mr. Jukes after being made aware of the events of the 27th and 28th September 2018 and after it was reported that he was threatening harm to others and to himself in conversation with a psychologist on the Znd October 2018. 4_ Clinicians within HTT did not make adequate attempts to locate and engage with Mr. Jukes after he failed to attend for medical review on the Ath October 2018,;
5. Clinicians within HTT did not offer Mr. Jukes' an urgent medical review when spoke to him on the morning of the 9th October 2018_ Following a post mortem the medical cause of death was determined to be: 1a) Hanging During the course of the inquest the evidence revealed matters giving rise to concern in such way that there is a risk that future deaths will occur unless action is taken The matters of concern are as follows_ 1 The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr: Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody. She was provided with a out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft;, threated suicide and harm to others and not come out in We understand that the Black Country Partnership NHS Foundation Trust are responding to you on this matter of concern: 2 The above psychiatric Iiaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT Iiaison and diversion team based at Barr custody suite and was informed that Mr. Jukes was not known to the service She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of the previous evening; It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred , Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn't explain why the nurse was left with the impression that he was not known to services_ It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise. If reliable information is not being passed there is a risk to life from ill-informed decision making: It is difficult for us to comment on this particular finding of the PFD as the liaison nurse remains unclear of who she spoke to or which service she contacted_ Nor is there any documented record of this contact within the Liaison and Diversion Service. Within our bed management service we have an arrangement for the identification for patients under our care. We do however recognise that if it were bed management that the nurse contacted, the existing arrangement failed to identify Mr Jukes We are therefore implementing a they print Perry
documented and recognised system within our bed management team for all such calls which includes phonetic spelling and other controls to ensure a consistent approach to this matter
3. Despite not being informed by the BCPFT Iiaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes: Despite this_ no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team: It is not known why this was. Not having a robust and effective system to out necessary assessments whilst a patient is detained in police custody lives at risk We are grateful to you for raising this matter with us as it has identified the need for a joint operating protocol to be developed between BSHMFT and the Liaison and Diversion Service in Sandwell We have been in liaison with this team and are scheduled to meet and develop this protocol in late September 2019.
4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the Znd October 2018 the HTT's only recorded attempt to contact Mr: Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife's phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance. There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before_ Failure to utilise all means of locating a patient whose whereabouts are unknown, who requires assessment and who is not making contact with the team lives at risk; We sincerely apologise for this matter: The matter of communication preferences is being addressed by the Trust in that we now have communication preference field within the clinical record RIO.
5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the Znd. There is no credible evidence he was discussed or a plan made to locate and assess him. No explanation was provided in evidence nor was evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at risk As you state, it is vitally important that clinical records are documented to evidence the care and treatment plans for patients that are discussed between clinicians. We have identified that when our Multi-Disciplinary Team meetings take place there is evidence of some inconsistency in the recording of discussions and outcomes in some areas In direct response to this finding we have increased administrative resources within our Home Treatment Teams to enable consistent administrative support to our Multi-Disciplinary Team meetings which in turn will ensure that outcomes are clearly recorded: In addition, we have commenced a Quality Improvement Project to develop clear standards for Multi- carry puts puts
Disciplinary Team meetings and recording requirements_ We apologise sincerely for this failing in our clinical record keeping for Mr Jukes_ 6 On the 9th October 2018 a HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass Were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018. By this time there was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances; had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact: The staff involved maintained in evidence that acted appropriately; evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk: No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues. In direct response to this matter of concern we are now reviewing our Home Treatment Team Operating Protocol to strengthen the requirement for nurse led triage and assessment screening and appropriate clinical escalation to a Consultant Psychiatrist Consultant Psychiatrist overview and scrutiny of each case would either be through direct clinical assessment or review or through input and direction within the multi-disciplinary team or through formal or informal supervision of doctors and other home treatment staff, We note the view of the team that they felt acted appropriately and are therefore also this sad incident as a Case Study in our new Clinical Risk Assessment and Management Training so that staff are fully alert to accumulative risk factors. This training is mandatory for all clinical staff in the Trust irrelevant of clinical profession or team. The first pilot of the new training model which also incorporates suicide prevention training is due to launch at the end of September 2019. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr: Jukes that was not recorded in his BSMHT RIO notes_ Furthermore, his Risk Screen was not updated after information came to HTT's attention that affected his risk assessment_ There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians maybe misled or iIl-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a message' 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to proper records and that this noncompliance will go undetected: they they using very they Key keep
We recognise the need for an improvement in clinical record keeping standards and how this is absolutely central to the effective care of our patients. We apologise that this was not evident within the case of Mr Jukes and are sincerely sorry for this failing: The importance of risk identification, formulation and recording forms a central part of our new Clinical Risk Assessment and Management Training which , as stated above, will be piloted from September 2019. In addition to this training, all staff irrelevant of discipline are required to undertaken annual training on information governance where the importance of clinical record keeping standards is also highlighted. We are conscious that our Home Treatment Teams have been operating within an environment of high demand and acuity and that this may at times compromise their ability to consistently meet the important standards that we expect of staff, We are investing a significant amount of new financial resource into our Home Treatment Team to increase workforce capacity _ This includes:
5.0 Full time Home Treatment Team Managers 2 positions have now been recruited to and a further 3 are currently out to advert 3 Full time Out of Hours Practitioners all posts are currently out to advert
5.0 Full time Additional Medical Middle Grades An additional 0.SWTE Psychologist in every Home treatment Team (currently out to advert) 4 full time Administrative posts to support Home Treatment Team activity and recording of MDT discussions In addition to this, we have launched two critical Quality Improvement Projects one is to develop and implement core MDT minimum standards for recording of clinical documentation; the second is to improve our care planning and clinical risk assessment processes_
8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team_ Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk Please see the actions that we are taking in relation to an increase in resources to all Home Treatment Teams alongside the Quality improvement Projects that are being taken forward to ensure that key aspects of record keeping are as effective streamlined as possible so that we are able to reduce duplicative entries for staff on the RIO record. In closing this response, we would like to assure you that we have taken the matters raised in your Regulation 28 report extremely seriously and once again apologise to Mrs Jukes: We hope that the above actions will make a difference to the experience of future patients in our care and thank you for formally raising these with our organisation. yet
Response received
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Dear Ms Brown Re: Regulation 28 report, prevention of future death pertaining to Mr David Jukes, deceased Firstly on behalf of Black Country Partnership NHS Foundation Trust may I extend our most sincere condolences to Mrs Jukes following the sad death of her husband Mr David Jukes.
During the course of the inquest the evidence revealed matters giving rise to concern in such a way that there is a risk that future deaths will occur unless action is taken. In response to you Regulation 28 report to prevent future deaths we have outlined below the actions Black Country Partnership has taken to address the matters of concern that affected our organisation.
1. The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody. She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threated suicide and harm to others and not come out in response to police negotiators. This information was not included in a verbal handover according to the nurse’s evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest At present Liaison and Diversion (L&D) nursing staff have read access only to the current electronic custody record (ICIS) and in line with standard operational procedures are instructed to ensure checks are undertaken and all available content on ICIS is reviewed. This is further supported by obtaining a verbal update from the police. To improve
Chair: Andrew Fry Chief Executive: Lesley Writtle
information sharing arrangements with police , senior L&D staff are engaged in the West Midlands wide implementation of the new electronic custody record (CONNECT). Once fully implemented, it will enable staff to access a wider array of information relevant to each case prior to assessment. They will also have read and write access where risk information can be recorded by nursing staff.
L&D leads will raise awareness of the outcome and learning from the regulation 28 PFD report through the Joint Operational Group held with police on a quarterly basis to engage with police colleagues and stress the need for a full handover prior to assessment in each and every case.
2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of the previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred. Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise. If reliable information is not being passed there is a risk to life from ill-informed decision making. Before acting on any referral, L&D staff will do full background checks. This is part of the triage process to establish previous history, risk, current care plans, treatment, compliance and medication for example so staff can make an informed judgement on who needs to be seen and the level of urgency. Local mental health databases are reviewed however when staff don’t have immediate access, neighbouring services will be telephoned to attain all relevant information. Across the L&D services we are also rolling out staff access to the Spine to give staff wider access to patient information. Unfortunately we have yet to ascertain why on this occasion the L&D staff member was advised by BSMHT that the patient was not known to services however meetings with Trust leads from BSMHT are being planned to consider how we can jointly strengthen communication pathways to prevent reoccurrence. Implementation of the MERIT system will further enable staff access to information from mental health Trusts in Birmingham and Coventry. Likewise Birmingham and Coventry staff will be authorised for access to MERIT, for mental health information about those records held on both Oasis systems covering the whole of the Black Country. Please note that all other concerns raised within the Regulation 28 report affected other NHS bodies and services not provided by BCPFT and therefore we have not commented on these outcomes. We have however approached both BSMHT and CWPT to consider
Chair: Andrew Fry Chief Executive: Lesley Writtle
engaging in a wider learning event to consider all outcomes and where processes can continue 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 they are embedded whilst sharing the outcome and lessons learnt with all affected staff across our Liaison and Diversion teams.
During the course of the inquest the evidence revealed matters giving rise to concern in such a way that there is a risk that future deaths will occur unless action is taken. In response to you Regulation 28 report to prevent future deaths we have outlined below the actions Black Country Partnership has taken to address the matters of concern that affected our organisation.
1. The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody. She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threated suicide and harm to others and not come out in response to police negotiators. This information was not included in a verbal handover according to the nurse’s evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest At present Liaison and Diversion (L&D) nursing staff have read access only to the current electronic custody record (ICIS) and in line with standard operational procedures are instructed to ensure checks are undertaken and all available content on ICIS is reviewed. This is further supported by obtaining a verbal update from the police. To improve
Chair: Andrew Fry Chief Executive: Lesley Writtle
information sharing arrangements with police , senior L&D staff are engaged in the West Midlands wide implementation of the new electronic custody record (CONNECT). Once fully implemented, it will enable staff to access a wider array of information relevant to each case prior to assessment. They will also have read and write access where risk information can be recorded by nursing staff.
L&D leads will raise awareness of the outcome and learning from the regulation 28 PFD report through the Joint Operational Group held with police on a quarterly basis to engage with police colleagues and stress the need for a full handover prior to assessment in each and every case.
2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of the previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred. Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise. If reliable information is not being passed there is a risk to life from ill-informed decision making. Before acting on any referral, L&D staff will do full background checks. This is part of the triage process to establish previous history, risk, current care plans, treatment, compliance and medication for example so staff can make an informed judgement on who needs to be seen and the level of urgency. Local mental health databases are reviewed however when staff don’t have immediate access, neighbouring services will be telephoned to attain all relevant information. Across the L&D services we are also rolling out staff access to the Spine to give staff wider access to patient information. Unfortunately we have yet to ascertain why on this occasion the L&D staff member was advised by BSMHT that the patient was not known to services however meetings with Trust leads from BSMHT are being planned to consider how we can jointly strengthen communication pathways to prevent reoccurrence. Implementation of the MERIT system will further enable staff access to information from mental health Trusts in Birmingham and Coventry. Likewise Birmingham and Coventry staff will be authorised for access to MERIT, for mental health information about those records held on both Oasis systems covering the whole of the Black Country. Please note that all other concerns raised within the Regulation 28 report affected other NHS bodies and services not provided by BCPFT and therefore we have not commented on these outcomes. We have however approached both BSMHT and CWPT to consider
Chair: Andrew Fry Chief Executive: Lesley Writtle
engaging in a wider learning event to consider all outcomes and where processes can continue 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 they are embedded whilst sharing the outcome and lessons learnt with all affected staff across our Liaison and Diversion teams.
Response received
View full response
1
NHS Birmingham and Solihull CCG: Response to the Birmingham and Solihull Coroner’s Regulation 28 report to prevent future deaths
1. Introduction
1.1 This report provides a response to the Birmingham and Solihull Coroner, in respect of the Regulation 28 report to prevent future deaths issued to NHS Birmingham and Solihull Clinical Commissioning Group (the CCG), relating to the death of David Jonothon Jukes.
1.2 The Regulation 28 report raises a number of concerns about the care provided to Mr Jukes between July 2018 and Mr Jukes death on 9th October 2018.
1.3 The CCG has previously provided a comprehensive report to the Senior Coroner for Birmingham and Solihull on mental health services in the area, in response to a previous Regulation 28 report to prevent future deaths. Much of the information contained in that report is pertinent to the circumstances of this particular case and, therefore, we will not seek to repeat those details in this response.
2. Background and context
2.1 On 17th July 2019, the CCG received a Regulation 28 Report to Prevent Future Deaths from the Birmingham and Solihull Coroner relating to the death, and subsequent inquest, of David Jonothon Jukes, who sadly passed away on 9th October 2018.
2.2 The CCG commissions mental health services for over 25s from Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) through an NHS standard contract. The standard contract sets out the required operational standards, as well as national and local quality requirements.
2.3 The CCG, through these contractual arrangements and through its quality function, has quality monitoring processes in place, which include serious incident reporting systems and improvement monitoring. All investigations into serious incidents are quality assured by the CCG to ensure that necessary actions are identified and implemented.
2.4 Statements submitted to the inquest confirm that Mr Jukes had been receiving care following a self-referral to West Midlands’ Transition, Intervention and Liaison Services, which prompted a referral to the Complex Treatment Service provided by BSMHFT.
2
2.5 It is further understood that Mr Jukes had contact with the Home Treatment Team, Black Country Partnership NHS Foundation Trust and West Midlands Police during the period between his initial self-referral and his death.
2.6 The CCG has no direct knowledge of these events and has ascertained this information through documents provided by HM Coroner and BSMHFT.
2.7 HM Coroner has identified a number of concerns around the care and treatment of Mr Jukes, which include concerns about communication, access to relevant information, risk assessment and record keeping.
2.8 These issues are largely within the remit of the provider organisations to resolve, and the CCG confirms that an appropriate action plan has been drawn up and completed by BSMHFT.
2.9 The CCG is unable to comment on actions taken by Black Country Partnership NHS Foundation Trust or West Midlands Police, which it is expected will be addressed in their respective responses to HM Coroner.
2.10 The West Midlands’ Transition, Intervention and Liaison Services is an NHS England commissioned service and it is understood that NHS England will be commenting on this service as part of their response to the Coroner.
2.11 There is a suggestion in evidence given to HM Coroner that risk assessment and record keeping may be compromised by a lack of capacity within the BSMHFT Home Treatment Team, and it is this issue that the CCG will address in this response. It is noted, however, that the root cause analysis investigation undertaken by BSMHFT does not identify capacity or resource as a contributing factor in the care and treatment issues.
2.12 On 6th August 2019 a multi-agency round table meeting was held to review the findings of the root cause analysis investigation carried out by BSMHFT, to work towards making a multi-agency action plan.
3. Understanding and responding to capacity and demand
3.1 Since 2016, the CCG (both in the current form and as three former CCGs, prior to the Birmingham and Solihull CCG merger on 01 April 2018) has taken a number of steps, with partner organisations, to understand and respond to concerns about capacity and demand within the local mental health system.
3.2 The CCG recognises that there has been increased demand for crisis mental health services since 2016, and has responded to this additional pressure with
3
increased funding and through working with Forward Thinking Birmingham (providers of mental health services across Birmingham and Solihull for those aged up to 25), BSMHFT and the local Sustainability and Transformation Partnership (the STP) to look at different ways of working throughout the system.
3.3 In addition, the CCG has been, and continues to work with, system partners to understand the reason for the increased need, and to look at how the system can be improved to make best use of the existing resources.
3.4 The CCG has participated in a meeting called by NHS England, an action from which was that NHS England would consider additional ways to facilitate cross agency working.
3.5 Work is now underway as part of that review to explore multi-agency learning.
3.6 The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment. Part of this approach involves the CCG being an active partner in the STP and the Mental Health Programme Delivery Board. The ambition of the STP is to achieve sustainability, through a strong focus on prevention and recovery.
3.7 Included in this programme is consideration of the need to reinforce services that already exist within secondary mental health services, by increasing the staffing levels in crisis resolution home treatment teams, whilst also understanding what an alternative crisis support service might look like.
3.8 The CCG has been working closely with both local mental health service providers and the third sector, with the aim of improving the service offer for people experiencing a mental health crisis. Stakeholders are working on designing community based services, which will increase accessibility for those in crisis and their families, to deliver the most appropriate support at the earliest opportunity.
3.9 As a result of partnership working and guidance from people with lived experience, the CCG has been successful in securing recurrent funding from two separate NHS England Transformational funds, totalling in the region of £2.6m (increasing to £2.9m), to support making these fundamental changes to how crisis is managed within the region.
3.10 From this funding, psychiatric liaison services within acute hospitals will receive £1.15m to increase staffing levels within all hospitals which have an emergency
4
department, with the aim of providing a more robust, specialist and diverse workforce, to help reduce waiting times, increase flow and improve patient experience.
3.11 A further £1.4m (increasing to £1.7m) will be spent on the development of a crisis pathway to increase the capacity in secondary mental health crisis services.
3.12 Part of this increased funding will be used to set up a network of four Crisis Cafés across the Birmingham and Solihull area. Each will be open seven nights a week and will be operated by MIND, the mental health charity. With a direct pathway into secondary crisis services and specialist understanding of available third sector interventions, this service will offer a community based setting for people to be able to seek the appropriate support when in a crisis.
3.13 In the future, significant funding will be allocated towards the establishment of crisis houses, an evidence based initiative which will complement inpatient mental health facilities for those who may need support managing higher levels of risk.
3.14 Through easier accessibility at an earlier opportunity, the intention is to help prevent people reaching crisis, and collectively these initiatives aim to improve the experience of those who find themselves in crisis and reduce the impact of crisis on other agencies across the region.
4 Conclusion
4.1 The CCG aspires to there being no avoidable deaths in Birmingham and Solihull and takes every reported unexplained death very seriously. The CCG is continuously working with providers to improve the quality and safety of services, as well as looking at new and innovative ways to improve all mental health services.
4.2 The CCG has previously provided HM Coroner with an overview of the steps being taken in response to the increased demand for mental health services in the region, and this response provides an update specifically on the measures taken to improve crisis care.
4.3 The CCG recognises the need to take a multiagency approach to the delivery of services and the prevention of deaths, including creating robust partnerships with mental health support services.
4.4 The CCG will continue to keep under review the pressures on mental health services and the need to develop new initiatives to manage patient flow and improve services.
NHS Birmingham and Solihull CCG: Response to the Birmingham and Solihull Coroner’s Regulation 28 report to prevent future deaths
1. Introduction
1.1 This report provides a response to the Birmingham and Solihull Coroner, in respect of the Regulation 28 report to prevent future deaths issued to NHS Birmingham and Solihull Clinical Commissioning Group (the CCG), relating to the death of David Jonothon Jukes.
1.2 The Regulation 28 report raises a number of concerns about the care provided to Mr Jukes between July 2018 and Mr Jukes death on 9th October 2018.
1.3 The CCG has previously provided a comprehensive report to the Senior Coroner for Birmingham and Solihull on mental health services in the area, in response to a previous Regulation 28 report to prevent future deaths. Much of the information contained in that report is pertinent to the circumstances of this particular case and, therefore, we will not seek to repeat those details in this response.
2. Background and context
2.1 On 17th July 2019, the CCG received a Regulation 28 Report to Prevent Future Deaths from the Birmingham and Solihull Coroner relating to the death, and subsequent inquest, of David Jonothon Jukes, who sadly passed away on 9th October 2018.
2.2 The CCG commissions mental health services for over 25s from Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) through an NHS standard contract. The standard contract sets out the required operational standards, as well as national and local quality requirements.
2.3 The CCG, through these contractual arrangements and through its quality function, has quality monitoring processes in place, which include serious incident reporting systems and improvement monitoring. All investigations into serious incidents are quality assured by the CCG to ensure that necessary actions are identified and implemented.
2.4 Statements submitted to the inquest confirm that Mr Jukes had been receiving care following a self-referral to West Midlands’ Transition, Intervention and Liaison Services, which prompted a referral to the Complex Treatment Service provided by BSMHFT.
2
2.5 It is further understood that Mr Jukes had contact with the Home Treatment Team, Black Country Partnership NHS Foundation Trust and West Midlands Police during the period between his initial self-referral and his death.
2.6 The CCG has no direct knowledge of these events and has ascertained this information through documents provided by HM Coroner and BSMHFT.
2.7 HM Coroner has identified a number of concerns around the care and treatment of Mr Jukes, which include concerns about communication, access to relevant information, risk assessment and record keeping.
2.8 These issues are largely within the remit of the provider organisations to resolve, and the CCG confirms that an appropriate action plan has been drawn up and completed by BSMHFT.
2.9 The CCG is unable to comment on actions taken by Black Country Partnership NHS Foundation Trust or West Midlands Police, which it is expected will be addressed in their respective responses to HM Coroner.
2.10 The West Midlands’ Transition, Intervention and Liaison Services is an NHS England commissioned service and it is understood that NHS England will be commenting on this service as part of their response to the Coroner.
2.11 There is a suggestion in evidence given to HM Coroner that risk assessment and record keeping may be compromised by a lack of capacity within the BSMHFT Home Treatment Team, and it is this issue that the CCG will address in this response. It is noted, however, that the root cause analysis investigation undertaken by BSMHFT does not identify capacity or resource as a contributing factor in the care and treatment issues.
2.12 On 6th August 2019 a multi-agency round table meeting was held to review the findings of the root cause analysis investigation carried out by BSMHFT, to work towards making a multi-agency action plan.
3. Understanding and responding to capacity and demand
3.1 Since 2016, the CCG (both in the current form and as three former CCGs, prior to the Birmingham and Solihull CCG merger on 01 April 2018) has taken a number of steps, with partner organisations, to understand and respond to concerns about capacity and demand within the local mental health system.
3.2 The CCG recognises that there has been increased demand for crisis mental health services since 2016, and has responded to this additional pressure with
3
increased funding and through working with Forward Thinking Birmingham (providers of mental health services across Birmingham and Solihull for those aged up to 25), BSMHFT and the local Sustainability and Transformation Partnership (the STP) to look at different ways of working throughout the system.
3.3 In addition, the CCG has been, and continues to work with, system partners to understand the reason for the increased need, and to look at how the system can be improved to make best use of the existing resources.
3.4 The CCG has participated in a meeting called by NHS England, an action from which was that NHS England would consider additional ways to facilitate cross agency working.
3.5 Work is now underway as part of that review to explore multi-agency learning.
3.6 The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment. Part of this approach involves the CCG being an active partner in the STP and the Mental Health Programme Delivery Board. The ambition of the STP is to achieve sustainability, through a strong focus on prevention and recovery.
3.7 Included in this programme is consideration of the need to reinforce services that already exist within secondary mental health services, by increasing the staffing levels in crisis resolution home treatment teams, whilst also understanding what an alternative crisis support service might look like.
3.8 The CCG has been working closely with both local mental health service providers and the third sector, with the aim of improving the service offer for people experiencing a mental health crisis. Stakeholders are working on designing community based services, which will increase accessibility for those in crisis and their families, to deliver the most appropriate support at the earliest opportunity.
3.9 As a result of partnership working and guidance from people with lived experience, the CCG has been successful in securing recurrent funding from two separate NHS England Transformational funds, totalling in the region of £2.6m (increasing to £2.9m), to support making these fundamental changes to how crisis is managed within the region.
3.10 From this funding, psychiatric liaison services within acute hospitals will receive £1.15m to increase staffing levels within all hospitals which have an emergency
4
department, with the aim of providing a more robust, specialist and diverse workforce, to help reduce waiting times, increase flow and improve patient experience.
3.11 A further £1.4m (increasing to £1.7m) will be spent on the development of a crisis pathway to increase the capacity in secondary mental health crisis services.
3.12 Part of this increased funding will be used to set up a network of four Crisis Cafés across the Birmingham and Solihull area. Each will be open seven nights a week and will be operated by MIND, the mental health charity. With a direct pathway into secondary crisis services and specialist understanding of available third sector interventions, this service will offer a community based setting for people to be able to seek the appropriate support when in a crisis.
3.13 In the future, significant funding will be allocated towards the establishment of crisis houses, an evidence based initiative which will complement inpatient mental health facilities for those who may need support managing higher levels of risk.
3.14 Through easier accessibility at an earlier opportunity, the intention is to help prevent people reaching crisis, and collectively these initiatives aim to improve the experience of those who find themselves in crisis and reduce the impact of crisis on other agencies across the region.
4 Conclusion
4.1 The CCG aspires to there being no avoidable deaths in Birmingham and Solihull and takes every reported unexplained death very seriously. The CCG is continuously working with providers to improve the quality and safety of services, as well as looking at new and innovative ways to improve all mental health services.
4.2 The CCG has previously provided HM Coroner with an overview of the steps being taken in response to the increased demand for mental health services in the region, and this response provides an update specifically on the measures taken to improve crisis care.
4.3 The CCG recognises the need to take a multiagency approach to the delivery of services and the prevention of deaths, including creating robust partnerships with mental health support services.
4.4 The CCG will continue to keep under review the pressures on mental health services and the need to develop new initiatives to manage patient flow and improve services.
Report Sections
Investigation and Inquest
On 15/10/2018 I commenced an investigation into the death of David Jonothan Jukes. The investigation concluded at the end of an inquest on 11th July 2019. The conclusion of the inquest was Mr. Jukes’ death was a result of suicide. Despite being open to a Home Treatment Team (‘HTT’) and the Complex Treatment Service (‘CTS’) within Birmingham and Solihull Mental Health Trust (‘BSMHT’) Mr. Jukes had not undergone an adequate assessment of his mental health by the time of his death as a result of the following:
i. At the time of attendance by the Liaison and Diversion practitioner at Oldbury custody suite on the 28th September 2018, the practitioner did not have full details of the events during the evening of the 27th into 28th from West Midlands Police nor access to records pertaining to his mental health held by his GP, the West Midlands Transition, Intervention and Liaison Service and BSMHT. With access to this information, she would have requested a Mental Health Act Assessment.
ii. A Psychiatrist did not attend to assess Mr. Jukes whilst he was in custody on 28th September 2019 contrary to normal HTT practice.
iii. Clinicians within HTT did not make adequate attempts to locate and engage with Mr. Jukes after being made aware of the events of the 27th and 28th September 2018 and after it was reported that he was threatening harm to others and to himself in a conversation with a psychologist on the 2nd October 2018.
iv. Clinicians within HTT did not make adequate attempts to locate and engage with Mr. Jukes after he failed to attend for medical review on the 4th October 2018;
v. Clinicians within HTT did not offer Mr. Jukes’ an urgent medical review when they spoke to him on the morning of the 9th October 2018. It is possible that a full assessment would have prevented Mr. Jukes’ death on the 9th October 2018 but it cannot be said that it would have been likely to prevent his death as it is not known what the outcome of such an assessment would have been nor to what extent any treatment following assessment would have been effective given the complex nature of his chronic condition, his alcohol and drug use and his hostility to mental health care providers.
i. At the time of attendance by the Liaison and Diversion practitioner at Oldbury custody suite on the 28th September 2018, the practitioner did not have full details of the events during the evening of the 27th into 28th from West Midlands Police nor access to records pertaining to his mental health held by his GP, the West Midlands Transition, Intervention and Liaison Service and BSMHT. With access to this information, she would have requested a Mental Health Act Assessment.
ii. A Psychiatrist did not attend to assess Mr. Jukes whilst he was in custody on 28th September 2019 contrary to normal HTT practice.
iii. Clinicians within HTT did not make adequate attempts to locate and engage with Mr. Jukes after being made aware of the events of the 27th and 28th September 2018 and after it was reported that he was threatening harm to others and to himself in a conversation with a psychologist on the 2nd October 2018.
iv. Clinicians within HTT did not make adequate attempts to locate and engage with Mr. Jukes after he failed to attend for medical review on the 4th October 2018;
v. Clinicians within HTT did not offer Mr. Jukes’ an urgent medical review when they spoke to him on the morning of the 9th October 2018. It is possible that a full assessment would have prevented Mr. Jukes’ death on the 9th October 2018 but it cannot be said that it would have been likely to prevent his death as it is not known what the outcome of such an assessment would have been nor to what extent any treatment following assessment would have been effective given the complex nature of his chronic condition, his alcohol and drug use and his hostility to mental health care providers.
Circumstances of the Death
On the 9th October 2018 at 15:09 Mr. Jukes was declared deceased by paramedics in the back garden of 179 Ridgacre Road, Quinton.
Due to childhood trauma and experiences in the armed forces, Mr. Jukes had been battling with mental illness for a long time; he abused illegal drugs and alcohol as a way of managing his condition. In around 2006 he was diagnosed with post traumatic stress disorder and was detained under the Mental Health Act for a brief period. He attempted to hang himself in 2016. In July 2018 he self-referred to the NHS West Midlands’ Transition, Intervention and Liaison Services (‘TILS’). Following an assessment by TILS on the 31st August 2018 he was referred to the Complex Treatment Service (‘CTS’), a new team within Birmingham and Solihull Mental Health Trust (‘BSMHT’) providing NHS care specifically for veterans. Unfortunately the service was not to be fully operational in the West Midlands until the end of September 2018 and therefore there was a delay in contacting him. During this period Mr. Jukes’ condition markedly deteriorated with he and his wife identifying that he was losing control during the weekend of the 15th September 2018 culminating in him taking an excess dose of his sleeping medication on Monday the 17th September 2018. Consequently he was referred to the Home Treatment Team (‘HTT’) within BSMHT. He was reviewed by CPNs at home on the 19th and 21st September at which time he did engage with services although showing resistance and was booked for a medical assessment. Despite attendances on the 24th and 27th September 2018 for medical assessment with a psychiatrist the assessment could not be completed because he was too difficult to assess, principally as a result of his profound mistrust of, and hostility towards, mental health services thought to derive from the failure of previous treatment. It was felt that his immediate risk of suicide and self harm was low.
However, during the evening of the 27th September 2018 he became extremely agitated and aggressive with his family ultimately barricading himself in his loft and threatening suicide and harm to anyone who tried to come in. Police negotiators attempted to coax Mr. Jukes out of the loft but after several hours it was deemed best to leave him. He was arrested on suspicion of assault during this incident after coming down from the loft on the 28th September 2018. Whilst at Oldbury custody suite awaiting interview a health care practitioner and a community psychiatric nurse from the police liaison and diversion service were asked to review him; he did not engage with assessment but displayed no immediate risk to self. He initially returned to the family home following his release without charge from custody on the 28th but then left during the afternoon of the 29th September 2018.
On the 2nd October he was contacted by the CTS psychologist. During this 20 minute phone-call the psychologist became extremely concerned about Mr. Jukes who was making threats against HTT and was indicating he had the means and a plan to end his own life. However, he would not disclose where he was. The Psychologist informed HTT with the hope that they would attempt to contact Mr. Jukes. HTT did not attempt to contact Mr. Jukes or his wife but decided to await a pre-planned medical review on the 4th October 2019. He did not attend that review and there is a record of a single unanswered call by HTT to contact him but it appears this was actually to his wife’s phone by mistake. The CTS psychologist called his mobile phone twice on the 4th October 2018 but the calls went to voicemail. She reported her concerns for him to West Midlands Police on the 5th October 2018 but as his location was unknown there was nothing the police could do at that time.
Mr. Jukes was seen to return to the vicinity of on the 7th October 2018 and the police were informed of his presence but no unit was available to attend during the next 48 hours. An attempt to contact HTT was also made by Mr. Jukes’ wife on the 8th October 2018 with the intention of making them aware of his location but the team did not return the call.
On the morning of the 9th October 2018 a HTT nurse spoke to Mr. Jukes on the phone to invite him to a medical review, it was suspected that he was intoxicated, he disclosed no immediate concerns and stated he would attend an appointment on the 12th October 2018. He told the nurse he was back at
There was no attempt to arrange a review of Mr. Jukes sooner.
At 10:23 on the 9th October, Police officers attended in response to a call from his wife that Mr. Jukes was at the address and needed to leave because a non-molestation order was being obtained. He was found sat in the rear garden; he told the officers he would charge his phone in the shed and go - he gave the officers no cause for concern and no grounds to remove him from the property. However, when court bailiffs attended to serve the non-molestation order later that day Mr. Jukes was found hanging from a ligature fixed to the garden gate. Post mortem testing has shown that Mr. Jukes was not under the influence of alcohol or drugs at the time of his death.
Following a post mortem the medical cause of death was determined to be: 1 a) HANGING
Due to childhood trauma and experiences in the armed forces, Mr. Jukes had been battling with mental illness for a long time; he abused illegal drugs and alcohol as a way of managing his condition. In around 2006 he was diagnosed with post traumatic stress disorder and was detained under the Mental Health Act for a brief period. He attempted to hang himself in 2016. In July 2018 he self-referred to the NHS West Midlands’ Transition, Intervention and Liaison Services (‘TILS’). Following an assessment by TILS on the 31st August 2018 he was referred to the Complex Treatment Service (‘CTS’), a new team within Birmingham and Solihull Mental Health Trust (‘BSMHT’) providing NHS care specifically for veterans. Unfortunately the service was not to be fully operational in the West Midlands until the end of September 2018 and therefore there was a delay in contacting him. During this period Mr. Jukes’ condition markedly deteriorated with he and his wife identifying that he was losing control during the weekend of the 15th September 2018 culminating in him taking an excess dose of his sleeping medication on Monday the 17th September 2018. Consequently he was referred to the Home Treatment Team (‘HTT’) within BSMHT. He was reviewed by CPNs at home on the 19th and 21st September at which time he did engage with services although showing resistance and was booked for a medical assessment. Despite attendances on the 24th and 27th September 2018 for medical assessment with a psychiatrist the assessment could not be completed because he was too difficult to assess, principally as a result of his profound mistrust of, and hostility towards, mental health services thought to derive from the failure of previous treatment. It was felt that his immediate risk of suicide and self harm was low.
However, during the evening of the 27th September 2018 he became extremely agitated and aggressive with his family ultimately barricading himself in his loft and threatening suicide and harm to anyone who tried to come in. Police negotiators attempted to coax Mr. Jukes out of the loft but after several hours it was deemed best to leave him. He was arrested on suspicion of assault during this incident after coming down from the loft on the 28th September 2018. Whilst at Oldbury custody suite awaiting interview a health care practitioner and a community psychiatric nurse from the police liaison and diversion service were asked to review him; he did not engage with assessment but displayed no immediate risk to self. He initially returned to the family home following his release without charge from custody on the 28th but then left during the afternoon of the 29th September 2018.
On the 2nd October he was contacted by the CTS psychologist. During this 20 minute phone-call the psychologist became extremely concerned about Mr. Jukes who was making threats against HTT and was indicating he had the means and a plan to end his own life. However, he would not disclose where he was. The Psychologist informed HTT with the hope that they would attempt to contact Mr. Jukes. HTT did not attempt to contact Mr. Jukes or his wife but decided to await a pre-planned medical review on the 4th October 2019. He did not attend that review and there is a record of a single unanswered call by HTT to contact him but it appears this was actually to his wife’s phone by mistake. The CTS psychologist called his mobile phone twice on the 4th October 2018 but the calls went to voicemail. She reported her concerns for him to West Midlands Police on the 5th October 2018 but as his location was unknown there was nothing the police could do at that time.
Mr. Jukes was seen to return to the vicinity of on the 7th October 2018 and the police were informed of his presence but no unit was available to attend during the next 48 hours. An attempt to contact HTT was also made by Mr. Jukes’ wife on the 8th October 2018 with the intention of making them aware of his location but the team did not return the call.
On the morning of the 9th October 2018 a HTT nurse spoke to Mr. Jukes on the phone to invite him to a medical review, it was suspected that he was intoxicated, he disclosed no immediate concerns and stated he would attend an appointment on the 12th October 2018. He told the nurse he was back at
There was no attempt to arrange a review of Mr. Jukes sooner.
At 10:23 on the 9th October, Police officers attended in response to a call from his wife that Mr. Jukes was at the address and needed to leave because a non-molestation order was being obtained. He was found sat in the rear garden; he told the officers he would charge his phone in the shed and go - he gave the officers no cause for concern and no grounds to remove him from the property. However, when court bailiffs attended to serve the non-molestation order later that day Mr. Jukes was found hanging from a ligature fixed to the garden gate. Post mortem testing has shown that Mr. Jukes was not under the influence of alcohol or drugs at the time of his death.
Following a post mortem the medical cause of death was determined to be: 1 a) HANGING
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.