Shaun Houghton
PFD Report
All Responded
Ref: 2023-0350
All 1 response received
· Deadline: 20 Nov 2023
Response Status
Responses
1 of 1
56-Day Deadline
20 Nov 2023
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 AI summary
A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without consulting senior clinicians, raising concerns about the decision-making process.
Responses
The Trust has developed a new Standard Operating Procedure for patients self-discharging against medical advice, which includes mandatory consultant review for Mental Health Act consideration, a junior doctor checklist, and ensures medication prescribing. This SOP is scheduled for ratification in January 2024 and dissemination by February 2024.
AI summary
View full response
Dear Mr Walsh
Re: Shaun Houghton (deceased)
I write further to your correspondence dated 25 September 2023. I am grateful to you for bringing these matters of concern to my attention. On behalf of Greater Manchester Mental Health NHS Foundation Trust (GMMH) I would like to offer Shaun’s family our sincere condolences for their loss.
Please see the Trust’s response in relation to the concerns you have raised, and the actions taken by the Trust below:
1. During the Inquest evidence was heard that:
I. There are 5 separate units at Atherleigh Park Hospital and the current self- discharge against medical advice procedures or policies are uniform across all 5 units and do not involve a referral to a Consultant or Senior Doctor before the patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983.
II. There is no check list in relation to self-discharge against medical advice patients for junior Doctors to refer to before the patient leaves the Hospital.
III. No medication was prescribed or dispensed to the Deceased at the time of self-discharge.
Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.
2. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews the procedures and policies to cover all 5 units at the Atherleigh Park Hospital in relation to self-discharge against medical advice patients, with a review to there being a written policy, including a check list to assist junior Doctors.
The Trust took the decision to review policies and procedures Trust wide in relation to self- discharge against medical advice. A small cohort of senior clinicians undertook this review. Following this review it was highlighted that there were variations in practice occurring across the Trust.
Once the review was completed, it was agreed that a single Trust wide Standard Operating Procedure (SOP) would be written and implemented to ensure that all areas of the Trust follow a standardised, good practice process (which includes a checklist) in relation to self-discharge against medical advice.
3. I further request that the Trust reviews the procedures and policies in relation to a referral to a Consultant or Senior Doctor before a self-discharge against medical advice patient leaves the Hospital to check whether the patient should be considered for detention under the Mental Health Act 1983.
The SOP makes clear that where a patient requests self-discharge against medical advice, a Consultant or Senior Doctor must be contacted for guidance. The Consultant or Senior Doctor is expected to be involved in conversations with junior doctors about any patient who requests their discharge against medical advice.
A mental state examination including both a capacity assessment and risk assessment will be undertaken. This will inform the most appropriate actions including consideration of whether a person is detainable under the Mental Health Act 1983, the use of the Mental Capacity Act or the Deprivation of Liberty Safeguard Policy
Within the new SOP, patients requesting their discharge against medical advice will have their mental capacity reviewed, initially utilising the two-stage test set out in the Mental Capacity Act 2005. Where the answer to both stages is yes, capacity will be further checked utilising the guidance in the Trust Mental Capacity Act and Deprivation of Liberty Safeguard Policy, and the outcome of this must be recorded on the Trust ‘Self Discharge of an Adult’ form.
4. I further request that the Trust reviews the procedures and policies in relation to the prescription and dispensing of medication before a self-discharge against medical advice patient leaves the Hospital
The SOP is clear that prescribed discharge medications must be supplied before a patient leaves the inpatient setting. The prescribing of medications will form part of the risk assessment process. This is also included in the checklist for ward staff that is to be completed when a self-discharge proceeds and is recorded in the patients care record. Section 4.1 of the Trust Medication Management Policy sets out the general principles to be followed for the supply of medications throughout the Trust. Section 4.2.2 outlines the principles for the supply of discharge prescriptions and medications which includes that medications must be received before a patient is discharged.
The SOP will be submitted for ratification in January 2024 to the oversight committee and once approved, will be issued to all Care Groups to be disseminated to staff. This is expected to be
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.
completed by February 2024. The SOP will be available to all staff on the Trust intranet and will be shared with junior doctors as part of their induction. The learning from this inquest and the new SOP will be shared in the Trust’s monthly Patient Safety Newsletter which is received by all staff.
The SOP can be shared once ratified if required.
, on behalf of the Trust can I thank you again for bringing these matters of concern to the Trust’s attention. I hope this response assures you of the Trust’s ongoing willingness to ensure the highest standards of patient care and I am grateful to you for your contribution to that endeavour. If you have any further questions in relation to the Trust’s response, please do let me know.
Re: Shaun Houghton (deceased)
I write further to your correspondence dated 25 September 2023. I am grateful to you for bringing these matters of concern to my attention. On behalf of Greater Manchester Mental Health NHS Foundation Trust (GMMH) I would like to offer Shaun’s family our sincere condolences for their loss.
Please see the Trust’s response in relation to the concerns you have raised, and the actions taken by the Trust below:
1. During the Inquest evidence was heard that:
I. There are 5 separate units at Atherleigh Park Hospital and the current self- discharge against medical advice procedures or policies are uniform across all 5 units and do not involve a referral to a Consultant or Senior Doctor before the patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983.
II. There is no check list in relation to self-discharge against medical advice patients for junior Doctors to refer to before the patient leaves the Hospital.
III. No medication was prescribed or dispensed to the Deceased at the time of self-discharge.
Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.
2. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews the procedures and policies to cover all 5 units at the Atherleigh Park Hospital in relation to self-discharge against medical advice patients, with a review to there being a written policy, including a check list to assist junior Doctors.
The Trust took the decision to review policies and procedures Trust wide in relation to self- discharge against medical advice. A small cohort of senior clinicians undertook this review. Following this review it was highlighted that there were variations in practice occurring across the Trust.
Once the review was completed, it was agreed that a single Trust wide Standard Operating Procedure (SOP) would be written and implemented to ensure that all areas of the Trust follow a standardised, good practice process (which includes a checklist) in relation to self-discharge against medical advice.
3. I further request that the Trust reviews the procedures and policies in relation to a referral to a Consultant or Senior Doctor before a self-discharge against medical advice patient leaves the Hospital to check whether the patient should be considered for detention under the Mental Health Act 1983.
The SOP makes clear that where a patient requests self-discharge against medical advice, a Consultant or Senior Doctor must be contacted for guidance. The Consultant or Senior Doctor is expected to be involved in conversations with junior doctors about any patient who requests their discharge against medical advice.
A mental state examination including both a capacity assessment and risk assessment will be undertaken. This will inform the most appropriate actions including consideration of whether a person is detainable under the Mental Health Act 1983, the use of the Mental Capacity Act or the Deprivation of Liberty Safeguard Policy
Within the new SOP, patients requesting their discharge against medical advice will have their mental capacity reviewed, initially utilising the two-stage test set out in the Mental Capacity Act 2005. Where the answer to both stages is yes, capacity will be further checked utilising the guidance in the Trust Mental Capacity Act and Deprivation of Liberty Safeguard Policy, and the outcome of this must be recorded on the Trust ‘Self Discharge of an Adult’ form.
4. I further request that the Trust reviews the procedures and policies in relation to the prescription and dispensing of medication before a self-discharge against medical advice patient leaves the Hospital
The SOP is clear that prescribed discharge medications must be supplied before a patient leaves the inpatient setting. The prescribing of medications will form part of the risk assessment process. This is also included in the checklist for ward staff that is to be completed when a self-discharge proceeds and is recorded in the patients care record. Section 4.1 of the Trust Medication Management Policy sets out the general principles to be followed for the supply of medications throughout the Trust. Section 4.2.2 outlines the principles for the supply of discharge prescriptions and medications which includes that medications must be received before a patient is discharged.
The SOP will be submitted for ratification in January 2024 to the oversight committee and once approved, will be issued to all Care Groups to be disseminated to staff. This is expected to be
Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.
completed by February 2024. The SOP will be available to all staff on the Trust intranet and will be shared with junior doctors as part of their induction. The learning from this inquest and the new SOP will be shared in the Trust’s monthly Patient Safety Newsletter which is received by all staff.
The SOP can be shared once ratified if required.
, on behalf of the Trust can I thank you again for bringing these matters of concern to the Trust’s attention. I hope this response assures you of the Trust’s ongoing willingness to ensure the highest standards of patient care and I am grateful to you for your contribution to that endeavour. If you have any further questions in relation to the Trust’s response, please do let me know.
Report Sections
Investigation and Inquest
On the 5th of December 2022 I commenced an Investigation into the death of Shaun Daniel Houghton, 35 years, born 5th of October 1987. The Investigation concluded at the end of the Inquest on the 26th of May 2023. The Medical Cause of Death was: - la Hanging The Conclusion of the Investigation was Shaun Daniel Houghton died as a consequence of self-suspension by Ligature but his intentions at the time remain unclear.
Circumstances of the Death
1. Shaun Daniel Houghton (hereinafter referred to as the "Deceased'') was found dead in a rural area near Dukes Barn Farm, Hall Lane, Winstanley, Wigan on the 1st of December 2022.
2. The Deceased suffered with diagnosed Emotionally Unstable Personality Disorder, Attention Deficit Hyperactive Disorder, Anxiety and Depression and Mental Health & Behaviour Disorder due to substance misuse.
3. On the 16th of November 2022 the Deceased was admitted to the Prospect Unit at Atherleigh Park Hospital, Atherleigh Way, Leigh, as a voluntary patient after his Partner contacted the Mental Health Crisis Team due to family concerns about his mental health and he received in patient treatment until he was discharged from the Hospital after a Multi-Disciplinary Team meeting on the 25th of November 2022.
4. On the 28th of November 2022 a Senior Nurse Practitioner from Greater Manchester Mental Health Trust visited the Deceased at his home address, and he demonstrated overwhelming feelings of anxiety and low mood. He indicated that he felt that he was impulsively going to end his life. Impulsivity is a recognised symptom of Attention Deficit Hyperactive Disorder and the Deceased continued to express thoughts, plans and intent to end his life. The Senior Nurse Practitioner arranged for the Deceased to be readmitted to the Sovereign Unit at Atherleigh Park Hospital as a voluntary patient later the same day.
5. On the 29th of November 2022 the Deceased was seen by an Associate Specialist Doctor in Psychiatry at the Hospital and a plan was created whereby the Deceased would remain in the Hospital as a voluntary patient with appropriate medication and he would be further reviewed in a Multi-Disciplinary Meeting the following week.
6. On the 30th of November 2022 the Deceased indicated that he wished to take his self-discharge from the Hospital, which was against medical advice, and he stated that he was unhappy with the Sovereign Unit at the Hospital, referring to the lack of Television remote controls on the Unit and he wanted to be moved to the Prospect Unit at the Hospital but a bed in the Prospect Unit was not available at the time.
7. The Deceased's wish to self-discharge was referred to the Doctor on call and he was seen by a Foundation Year 2 Doctor, a junior Doctor, who had only spent a period of 4 months in Psychiatry as part of his general training as a Doctor. The Doctor followed the training he had been given in relation to self-discharge patients and he conducted an assessment in relation to the capacity of the Deceased and a risk assessment in relation to the Deceased but he did not consult or refer the self-discharge to the Senior Doctor who had created the plan of treatment on the previous day or the Consultant, both of whom were in the Hospital at the time. It is unclear from the evidence whether a referral to the Senior Doctor or the Consultant would have changed the decision to allow the Deceased to self-discharge and leave the Hospital or whether a referral would have led
2. The Deceased suffered with diagnosed Emotionally Unstable Personality Disorder, Attention Deficit Hyperactive Disorder, Anxiety and Depression and Mental Health & Behaviour Disorder due to substance misuse.
3. On the 16th of November 2022 the Deceased was admitted to the Prospect Unit at Atherleigh Park Hospital, Atherleigh Way, Leigh, as a voluntary patient after his Partner contacted the Mental Health Crisis Team due to family concerns about his mental health and he received in patient treatment until he was discharged from the Hospital after a Multi-Disciplinary Team meeting on the 25th of November 2022.
4. On the 28th of November 2022 a Senior Nurse Practitioner from Greater Manchester Mental Health Trust visited the Deceased at his home address, and he demonstrated overwhelming feelings of anxiety and low mood. He indicated that he felt that he was impulsively going to end his life. Impulsivity is a recognised symptom of Attention Deficit Hyperactive Disorder and the Deceased continued to express thoughts, plans and intent to end his life. The Senior Nurse Practitioner arranged for the Deceased to be readmitted to the Sovereign Unit at Atherleigh Park Hospital as a voluntary patient later the same day.
5. On the 29th of November 2022 the Deceased was seen by an Associate Specialist Doctor in Psychiatry at the Hospital and a plan was created whereby the Deceased would remain in the Hospital as a voluntary patient with appropriate medication and he would be further reviewed in a Multi-Disciplinary Meeting the following week.
6. On the 30th of November 2022 the Deceased indicated that he wished to take his self-discharge from the Hospital, which was against medical advice, and he stated that he was unhappy with the Sovereign Unit at the Hospital, referring to the lack of Television remote controls on the Unit and he wanted to be moved to the Prospect Unit at the Hospital but a bed in the Prospect Unit was not available at the time.
7. The Deceased's wish to self-discharge was referred to the Doctor on call and he was seen by a Foundation Year 2 Doctor, a junior Doctor, who had only spent a period of 4 months in Psychiatry as part of his general training as a Doctor. The Doctor followed the training he had been given in relation to self-discharge patients and he conducted an assessment in relation to the capacity of the Deceased and a risk assessment in relation to the Deceased but he did not consult or refer the self-discharge to the Senior Doctor who had created the plan of treatment on the previous day or the Consultant, both of whom were in the Hospital at the time. It is unclear from the evidence whether a referral to the Senior Doctor or the Consultant would have changed the decision to allow the Deceased to self-discharge and leave the Hospital or whether a referral would have led
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.