Sharon Kelly
PFD Report
Partially Responded
Ref: 2020-0250
1 of 3 responded · Over 2 years old
Response Status
Responses
1 of 3
56-Day Deadline
8 Jan 2021
Over 2 years old — no identified published response
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
• Whether there is sufficiently clear training at EEASin relation to (1) identifying relevant flag markers to ensure police attendance ata property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
• Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019)
• Whether there is sufficient clarity in the training for Essex Police Comms Officers as to the circumstances in which a blue lights response should be mandated (in light of the evidence of Insp as to the response on 27 June 2019)
• Whether EPUT can review its arrangements for convening an urgent MHS assessment, in conjunction with social services. (in light of the jury’s findings with regard to the MHA assessment in June 2019)
• Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019)
• Whether there is sufficient clarity in the training for Essex Police Comms Officers as to the circumstances in which a blue lights response should be mandated (in light of the evidence of Insp as to the response on 27 June 2019)
• Whether EPUT can review its arrangements for convening an urgent MHS assessment, in conjunction with social services. (in light of the jury’s findings with regard to the MHA assessment in June 2019)
Responses
Response received
View full response
Dear Mrs Beasley-Murray,
I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 25th November 2020, which was issued following the inquest into the death of Sharon Kelly.
I would like to begin by extending my deepest condolences to the family of Ms Kelly. This has been an extremely difficult time for them and I hope that my response provides the family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issue of concern raised in your report.
In response to the matter of concern regarding whether EPUT can review its arrangements for convening urgent Mental Health Act Assessments in conjunction with social services, I can confirm that a strong collaborative relationship exists between EPUT and ECC which reflects, develops and undertakes continuous improvement initiatives.
In response to your concern, the Trust’s Associate Director for Social Care and the ECC Service Manager for Mental Health have jointly reviewed the current processes and have identified the following actions to be implemented by the Trust:
1. The Trust will ensure that referrals for urgent MHA assessments are accompanied by a telephone conversation between the referrer and the Emergency Duty Service (out of hours) and the Approved Mental Health Professional (AMHP) hub.
2. Risks indicated by the referral will be made explicit in both the referral and the accompanying telephone call by the referrer.
3. The timing of the MHA assessment to be explored with the referrer and any accompanying risk/system issues are to be made explicit so that the management of risk can be agreed/mitigated.
I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust’s top priority.
I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 25th November 2020, which was issued following the inquest into the death of Sharon Kelly.
I would like to begin by extending my deepest condolences to the family of Ms Kelly. This has been an extremely difficult time for them and I hope that my response provides the family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issue of concern raised in your report.
In response to the matter of concern regarding whether EPUT can review its arrangements for convening urgent Mental Health Act Assessments in conjunction with social services, I can confirm that a strong collaborative relationship exists between EPUT and ECC which reflects, develops and undertakes continuous improvement initiatives.
In response to your concern, the Trust’s Associate Director for Social Care and the ECC Service Manager for Mental Health have jointly reviewed the current processes and have identified the following actions to be implemented by the Trust:
1. The Trust will ensure that referrals for urgent MHA assessments are accompanied by a telephone conversation between the referrer and the Emergency Duty Service (out of hours) and the Approved Mental Health Professional (AMHP) hub.
2. Risks indicated by the referral will be made explicit in both the referral and the accompanying telephone call by the referrer.
3. The timing of the MHA assessment to be explored with the referrer and any accompanying risk/system issues are to be made explicit so that the management of risk can be agreed/mitigated.
I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust’s top priority.
Report Sections
Investigation and Inquest
On 27 June 2019 I commenced an investigation into the death of Sharon Louise Kelly aged 44 years old. The investigation concluded at the end of the inquest on 12 November2019. The conclusion of the inquest was Sharon Louise Kelly killed herself. The contributing factors were as follows:-
• The timing of the Mental Health Act assessment was inadequate
• Failure to initiate the risk assessment upon arrival at the property by the EEAS
• Widespread insufficient communication between all services. including medical cause of death and short-form conclusion or narrative conclusion summarised]. The medical cause of death was 1a) hanging
11) alcohol and multiple drug overdose
• The timing of the Mental Health Act assessment was inadequate
• Failure to initiate the risk assessment upon arrival at the property by the EEAS
• Widespread insufficient communication between all services. including medical cause of death and short-form conclusion or narrative conclusion summarised]. The medical cause of death was 1a) hanging
11) alcohol and multiple drug overdose
Circumstances of the Death
Ms Kelly had a long history of mental health and alcohol problems with frequent suicide attempts. She informed a family member that she would kill herself on the anniversary of her baby son’s death. The ambulance attended her property but did not enter, awaiting police attendance which was delayed. When, eventually the services entered the property Ms Kelly was deceased.
Inquest Conclusion
-
• The timing of the Mental Health Act assessment was inadequate
• Failure to initiate the risk assessment upon arrival at the property by the EEAS
• Widespread insufficient communication between all services. including medical cause of death and short-form conclusion or narrative conclusion summarised]. The medical cause of death was 1a) hanging
11) alcohol and multiple drug overdose
• The timing of the Mental Health Act assessment was inadequate
• Failure to initiate the risk assessment upon arrival at the property by the EEAS
• Widespread insufficient communication between all services. including medical cause of death and short-form conclusion or narrative conclusion summarised]. The medical cause of death was 1a) hanging
11) alcohol and multiple drug overdose
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.