Patricia Ferguson
PFD Report
All Responded
Ref: 2020-0155
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
All 2 responses received
· Deadline: 18 Jun 2020
Sent To
- Bassetlaw Clinical Commissioning Group
- Mansfield and Ashfield Clinical Commissioning Group
- Newark and Sherwood Clinical Commissioning Group
- Nottingham City Clinical Commissioning Group
- Nottingham North and East Clinical Commissioning Group
- Nottingham West Clinical Commissioning Group
- Rushcliffe Clinical Commissioning Group
Response Status
Responses
2 of 7
56-Day Deadline
18 Jun 2020
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 Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation that there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular.
(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths.
(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths.
Responses
Response received
View full response
Dear Mr Clow
Re: Regulation 28: Report to prevent future deaths
I am writing in response to the Regulation 28 report to prevent future deaths that was received by NHS Bassetlaw CCG on 23rd April 2020, information has been provided on each of the points that were raised and is outlined below.
In the Regulation 28 report to prevent future deaths you stated that:
1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation that there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular.
(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths.
NHS Bassetlaw CCG (BCCG) has taken the following actions with regard to this issue;
The BCCG is working in partnership with Nottinghamshire Healthcare NHS Trust (NHT) on a programme of transformation to meet the requirements of the NHS Long Term Plan (LTP) over the next 5 years.
The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support testing new delivery models.
Continued…….
Dr
Chair Chief Officer
The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).
The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence-based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment each year to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the BCCG and the Transformation plan is reviewed by NHS England on a monthly basis. BCCG have planned monthly transformation meetings with NHT commencing which were due to commence in March 2020. However, this has recently been impacted by the COVID-19 pandemic and has commenced week of 1st June 2020.
Currently, there is an agreed specification for community mental health teams which Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.
The Long Term Plan, which I have referenced above, provides a blueprint for standardised service delivery models to be implemented across England, ensuring evidence based models of care are commissioned and delivered, progress to implement a revised service model has already been made in Nottinghamshire.
I hope that this information provides assurance that the BCCG is taking the required action to address your concerns. Please do not hesitate to contact me if you require any additional information.
Re: Regulation 28: Report to prevent future deaths
I am writing in response to the Regulation 28 report to prevent future deaths that was received by NHS Bassetlaw CCG on 23rd April 2020, information has been provided on each of the points that were raised and is outlined below.
In the Regulation 28 report to prevent future deaths you stated that:
1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation that there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular.
(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths.
NHS Bassetlaw CCG (BCCG) has taken the following actions with regard to this issue;
The BCCG is working in partnership with Nottinghamshire Healthcare NHS Trust (NHT) on a programme of transformation to meet the requirements of the NHS Long Term Plan (LTP) over the next 5 years.
The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support testing new delivery models.
Continued…….
Dr
Chair Chief Officer
The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).
The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence-based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment each year to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the BCCG and the Transformation plan is reviewed by NHS England on a monthly basis. BCCG have planned monthly transformation meetings with NHT commencing which were due to commence in March 2020. However, this has recently been impacted by the COVID-19 pandemic and has commenced week of 1st June 2020.
Currently, there is an agreed specification for community mental health teams which Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.
The Long Term Plan, which I have referenced above, provides a blueprint for standardised service delivery models to be implemented across England, ensuring evidence based models of care are commissioned and delivered, progress to implement a revised service model has already been made in Nottinghamshire.
I hope that this information provides assurance that the BCCG is taking the required action to address your concerns. Please do not hesitate to contact me if you require any additional information.
Response received
View full response
Dear Mr Clow
Regulation 28: Report to prevent future deaths– Patricia Ferguson
I am writing in response to the report that was received by Nottingham and Nottinghamshire CCG on 23rd April 2020, please note that this response covers Nottingham and Nottinghamshire CCG; Bassetlaw CCG have a separate contract with Nottinghamshire Healthcare NHS Trust. Information has been provided on each of the points that were raised and is outlined below.
In the report you stated that:
1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation that there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular.
(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths.
The CCG was asked to take the following action;
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
The CCG is working in partnership with Nottinghamshire Healthcare NHS Trust (NHT) on a programme of transformation to meet the requirements of the NHS Long Term Plan (LTP) over the next 5 years.
The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support testing new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).
The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence- based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment each year to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the CCG and the Transformation plan is reviewed by NHS England on a monthly basis. A Steering Group meets on a monthly basis to oversee the transformation of the Adult and Older Adult Community model. However, this has recently been impacted by the COVID-19 pandemic and will recommence in due course.
Currently, there is an agreed specification for community mental health teams which outlines the aims, objectives and outcomes for the service. Nottinghamshire Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.
The Long Term Plan, which I have referenced above, provides a blueprint for standardised service delivery models to be implemented across England, ensuring evidence based models of care are commissioned and delivered, progress to implement a revised service model has already been made in Nottinghamshire.
I hope that this information provides assurance that the CCG is already taking the required action to address your concerns. Please do not hesitate to contact me if you require any additional information.
Regulation 28: Report to prevent future deaths– Patricia Ferguson
I am writing in response to the report that was received by Nottingham and Nottinghamshire CCG on 23rd April 2020, please note that this response covers Nottingham and Nottinghamshire CCG; Bassetlaw CCG have a separate contract with Nottinghamshire Healthcare NHS Trust. Information has been provided on each of the points that were raised and is outlined below.
In the report you stated that:
1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation that there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular.
(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths.
The CCG was asked to take the following action;
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
The CCG is working in partnership with Nottinghamshire Healthcare NHS Trust (NHT) on a programme of transformation to meet the requirements of the NHS Long Term Plan (LTP) over the next 5 years.
The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support testing new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).
The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence- based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment each year to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the CCG and the Transformation plan is reviewed by NHS England on a monthly basis. A Steering Group meets on a monthly basis to oversee the transformation of the Adult and Older Adult Community model. However, this has recently been impacted by the COVID-19 pandemic and will recommence in due course.
Currently, there is an agreed specification for community mental health teams which outlines the aims, objectives and outcomes for the service. Nottinghamshire Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.
The Long Term Plan, which I have referenced above, provides a blueprint for standardised service delivery models to be implemented across England, ensuring evidence based models of care are commissioned and delivered, progress to implement a revised service model has already been made in Nottinghamshire.
I hope that this information provides assurance that the CCG is already taking the required action to address your concerns. Please do not hesitate to contact me if you require any additional information.
Action Should Be Taken
You should consider whether or not commissioning arrangements for CMHTs represent an appropriate balance of available resources in line with the best available guidance.
Report Sections
Investigation and Inquest
An inquest was opened into the death of Patricia Ferguson on the 9th May 2019 and concluded on the 15th August 2019. The conclusion of the inquest was that the death was suicide. Prior to the death Patricia Ferguson had been in receipt of secondary mental health services from her local Community Mental Health Team. The care afforded by the clinicians working with Patricia Ferguson was good. The psychiatrist and community psychiatric nurse working with Patricia Ferguson formed the clinical view that she would benefit from direct work from a clinical psychologist. A clinical psychologist was not, however, available to carry out direct work.
Circumstances of the Death
Patricia Ferguson suffered significant mental ill health at times. She was admitted as an inpatient on one occasion and on other occasions she received secondary mental healthcare including medication, regular review from a Consultant Psychiatrist and support from Community Psychiatric Nurses. When unwell, Patricia Ferguson would typically be overwhelmed with negative thoughts and emotions on a particular issue. This led to her completed suicide. The clinicians working with Patricia Ferguson considered that the particular type of interventions which can only be undertaken by a clinical psychologist would be of benefit to Patricia Ferguson.
The inquest heard evidence from Nottinghamshire Healthcare NHS Trust regarding staff establishment within CMHTs. A clinical psychologist was employed by the CMHT working with Patricia Ferguson but was unable to take on new patients as there was going to be a planned period of extended absence.
The inquest heard evidence that clinical psychology was a ‘precious resource’ within the CMHTs. In terms of clinical psychology posts, the inquest heard that in some CMHTs within Nottinghamshire there is a full time equivalent post and in other teams this may be a shared post, or a less than full-time equivalent post. No teams have more than one clinical psychologist.
I was satisfied that Nottinghamshire Healthcare NHS Trust have implemented measures to make the best use of their clinical psychologists by means of a new internal protocol.
The inquest heard evidence from Nottinghamshire Healthcare NHS Trust regarding staff establishment within CMHTs. A clinical psychologist was employed by the CMHT working with Patricia Ferguson but was unable to take on new patients as there was going to be a planned period of extended absence.
The inquest heard evidence that clinical psychology was a ‘precious resource’ within the CMHTs. In terms of clinical psychology posts, the inquest heard that in some CMHTs within Nottinghamshire there is a full time equivalent post and in other teams this may be a shared post, or a less than full-time equivalent post. No teams have more than one clinical psychologist.
I was satisfied that Nottinghamshire Healthcare NHS Trust have implemented measures to make the best use of their clinical psychologists by means of a new internal protocol.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.