Daniel Nelson
PFD Report
All Responded
Ref: 2022-0282
All 1 response received
· Deadline: 8 Nov 2022
Response Status
Responses
1 of 1
56-Day Deadline
8 Nov 2022
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
The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a significant systemic gap in patient management.
Responses
The Trust has updated its clinical record system (Paris) to automatically flag Section 117 aftercare eligibility. A Section 117 Aftercare Policy has been developed and is awaiting ratification, and updated Section 117 training is being delivered across all sites.
AI summary
View full response
Dear Mr Rheinberg
Re: Daniel Nelson (deceased) Regulation 28 Preventing Future Deaths Response
On behalf of Greater Manchester Mental Health NHS Trust (GMMH) I would like to offer Mr Nelson’s family our sincere condolences at this difficult time.
Mr Rheinberg, thank you for highlighting your concerns during Ms Nelson’s Inquest which concluded on 12th September 2022.
On behalf of the Trust can I apologise that you have had to bring these matters of concern to the Trust’s attention.
Please see the Trust’s response in relation to the concerns you have raised, and the actions taken by the Trust:
Within the Trust there was no protocol, policy or adequate standard operating procedures governing section 117 discharges.
The Trust has a Section 117 Project Group that has developed a Section 117 Aftercare Policy that addresses responsibilities of services to someone who is subject to Section 117 of the Mental Health Act 1983 (MHA). The policy has been widely consulted upon and is due to be ratified at the Trust Mental Health Act and Mental Capacity Act Compliance Committee on 24th November 2022. Following ratification the policy will be shared with staff through the Social Care Leads in each division of the Trust. The policy will be uploaded to the Trust intranet and will be shared with staff through the Trust’s weekly communication briefing and the Trust Patient Safety Newsletter.
In addition to the policy the Trust Section 117 Project Group has reviewed and updated the existing training in respect of Section 117 and staff responsibilities that will be delivered to staff on a quarterly basis. This group has developed training aimed at members of multi- disciplinary teams working in the Trust inpatient wards that is being delivered across all sites. Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL
The Trust’s clinical record, Paris, has been updated and now automatically displays a ‘flag’ to identify aftercare eligibility for those patients who have a history of detentions within GMMH. The flag will remain live on the person’s clinical record until Section 117 duties are ended via a formal review and Section 117 discharge process.
Across GMMH learning from incidents to reduce the risk of reoccurrence is key. Learning events are either held locally within the team or division that the incident occurred and /or the Trust hold larger Trust wide learning events where the details and learning from either one incident or a group of similar themes identified are shared with staff across the Trust. These events are held monthly. On 16th December 2022 the learning event being delivered is Safe Discharge and 117 Responsibilities – a Salford case study where the learning from events surrounding Mr Nelson’s discharge and subsequent death will be shared along with resulting Trust developments. Following the event the learning is summarising in a briefing that is shared with staff and uploaded to the Trust’s Patient Safety intranet page.
Mr Rheinberg, on behalf of the Trust can I thank you for bringing these matters of concern to the Trust’s attention. I hope this response demonstrates to you and Mr Nelson’s family that GMMH have taken the concerns you have raised seriously. If you have any further questions in relation to the Trust’s response, please do let me know.
Re: Daniel Nelson (deceased) Regulation 28 Preventing Future Deaths Response
On behalf of Greater Manchester Mental Health NHS Trust (GMMH) I would like to offer Mr Nelson’s family our sincere condolences at this difficult time.
Mr Rheinberg, thank you for highlighting your concerns during Ms Nelson’s Inquest which concluded on 12th September 2022.
On behalf of the Trust can I apologise that you have had to bring these matters of concern to the Trust’s attention.
Please see the Trust’s response in relation to the concerns you have raised, and the actions taken by the Trust:
Within the Trust there was no protocol, policy or adequate standard operating procedures governing section 117 discharges.
The Trust has a Section 117 Project Group that has developed a Section 117 Aftercare Policy that addresses responsibilities of services to someone who is subject to Section 117 of the Mental Health Act 1983 (MHA). The policy has been widely consulted upon and is due to be ratified at the Trust Mental Health Act and Mental Capacity Act Compliance Committee on 24th November 2022. Following ratification the policy will be shared with staff through the Social Care Leads in each division of the Trust. The policy will be uploaded to the Trust intranet and will be shared with staff through the Trust’s weekly communication briefing and the Trust Patient Safety Newsletter.
In addition to the policy the Trust Section 117 Project Group has reviewed and updated the existing training in respect of Section 117 and staff responsibilities that will be delivered to staff on a quarterly basis. This group has developed training aimed at members of multi- disciplinary teams working in the Trust inpatient wards that is being delivered across all sites. Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL
The Trust’s clinical record, Paris, has been updated and now automatically displays a ‘flag’ to identify aftercare eligibility for those patients who have a history of detentions within GMMH. The flag will remain live on the person’s clinical record until Section 117 duties are ended via a formal review and Section 117 discharge process.
Across GMMH learning from incidents to reduce the risk of reoccurrence is key. Learning events are either held locally within the team or division that the incident occurred and /or the Trust hold larger Trust wide learning events where the details and learning from either one incident or a group of similar themes identified are shared with staff across the Trust. These events are held monthly. On 16th December 2022 the learning event being delivered is Safe Discharge and 117 Responsibilities – a Salford case study where the learning from events surrounding Mr Nelson’s discharge and subsequent death will be shared along with resulting Trust developments. Following the event the learning is summarising in a briefing that is shared with staff and uploaded to the Trust’s Patient Safety intranet page.
Mr Rheinberg, on behalf of the Trust can I thank you for bringing these matters of concern to the Trust’s attention. I hope this response demonstrates to you and Mr Nelson’s family that GMMH have taken the concerns you have raised seriously. If you have any further questions in relation to the Trust’s response, please do let me know.
Report Sections
Investigation and Inquest
On 21st May 2020 an investigation was commenced into the death of Daniel Robert Nelson aged 37. The investigation concluded at the end of the inquest on 12th September 2022. The conclusion of the inquest was that the deceased died as a result of heroin toxicity, that his death was drug related and that failings of the Trust in relation to among other things, section 117 obligations, contributed to the death.
Circumstances of the Death
The deceased had a long history of a dual diagnosis of schizophrenia and drug dependency. Following years of homelessness and imprisonment he was sectioned under section 3 of the Mental Health Act 1883 (“the Act”) and received treatment in the Eagleton Ward of the Meadowbrook Unit in Salford. He was discharged from section 3 care with an inadequate discharge plan and the requirements of section 117 of the Act were not met. He was housed in unsuitable emergency accommodation, without adequate support, in circumstances where he had access to drugs and subsequently died as a result of an accidental heroin overdose. The evidence revealed that with proper discharge planning and care his death would probably have been avoided. Staff on the Eagleton Ward had insufficient knowledge in relation to discharge planning and duties, particularly where, as in this case, the discharge was to an area outside Manchester. Within the Trust there was no protocol, policy or adequate standard operating procedures governing section 117 discharges
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.