Phephisa Mabuza
PFD Report
All Responded
Ref: 2024-0487
All 1 response received
· Deadline: 6 Nov 2024
Response Status
Responses
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56-Day Deadline
6 Nov 2024
All responses received
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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) Essex Partnership University NHS Foundation Trust Crisis Response Service follows the UK Mental Health Triage scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. The scale is embedded within the 111 Triage form utilised by clinicians in their clinical decision making following a triage. The Trust has departed from the national guidance for category D presentations such that the local guidance has been amended to reflect a 7 day response when the national guidance states 72 hours (2) Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours-same day response@ and do not reflect the scale on the 111 Triage form or the national guidance. I delayed issuing this report so that the Trust could inform me of the current position and whether any remedial action had been taken. A memo has been sent to all staff to notify them that the operational policy has been wrongly coded but a decision had not yet been taken as to whether and how the Trust intended to move forward in respect of the departure from the national guidance
Responses
Essex Partnership University NHS Foundation Trust has reviewed and amended its Crisis Response Service policy to align Category D presentations with national guidance (within 72 hours) and rectified incorrect triage response times for Codes D and E in its Standard Operational Policy. Memos have been sent to clinicians to ensure awareness of these updates.
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Dear Ms Harding,
Phephisa Siphelele Mabuza (RIP)
I write 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 15th July 2024 in respect of the above, which was issued following the inquest into the sad death of Phephisa Mabuza.
I would like to begin by extending my deepest condolences to Phephisa Mabuza’s family. The Trust sympathises with their very sad loss.
The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to these concerns in the hope that this provides both yourself and Phephisa Mabuza’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised.
I should say at this point, that in considering our replies we have again reviewed / confirmed the assurances previously provided to your Court. Each concern however has been looked at afresh, and has been cascaded to team leads.
Concern a)
“Essex Partnership University NHS Foundation Trust Crisis Response Service follows the UK Mental Health Triage scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. The scale is embedded within the 111 Triage form utilised by clinicians in their clinical decision making following a triage.
The Trust has departed from the national guidance for category D presentations such that the local guidance has been amended to reflect a 7 day response when the national guidance states 72 hours”
Response:
The Crisis Response Services (CRS) across the Trust follow the UK Mental Health Triage Scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. This form of triage scale is only used within the Crisis Response team. Whilst this guidance is not produced by NICE, it is the accepted guideline for use across the country for those organisations who offer this service.
Since CRS was started at the Trust in 2020, the scale is embedded with our 111 Triage form and offers guidance to clinicians in their clinical decision-making following a triage, however Category D has been
amended to reflect 7 days. During our investigations, the Trust was unable identify exactly why the decision was taken, however it appears to have been done to align with our community services in their operational frameworks, as the Trust embedded CRS into its services. In light of this, the senior management in the CRS and the Business Partners, have met to take forward this point. We now have clear clinical rationale frameworks, consistency, and appropriate and safe time frames for our patients coming through CRS.
Additionally work is underway in order to ensure Trust Policies align with national standards as required.
Concern b)
“Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours- same day response and do not reflect the scale on the 111 Triage form or the national guidance”.
Response:
The existing Standard Operational Policy in place is only for use by the Crisis Response Services across the Trust. It is acknowledged that the triage response times on Triage Codes D and E on the appendix were incorrectly stated as “Within 24 hours – Same Day” response, and do not reflect the scale on the form in use on the clinical system. This was owing to a typing error when the policy was completed, and that was unfortunately not picked up before the document went live. The Trust sincerely apologises for missing this, and the confusion it caused to both the Court and to the family.
The Standard Operational Policy has been reviewed and the identified errors rectified. A memo has been sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale in informing their clinical judgment in the decision making process. This has also been shared with the leads covering the other CRS teams.
I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We appreciate that there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care.
Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above.
We trust that your Court will share, as standard, a copy of this reply with Phephisa Mabuza’s family
Yours sincerel Chief Executive
Phephisa Siphelele Mabuza (RIP)
I write 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 15th July 2024 in respect of the above, which was issued following the inquest into the sad death of Phephisa Mabuza.
I would like to begin by extending my deepest condolences to Phephisa Mabuza’s family. The Trust sympathises with their very sad loss.
The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to these concerns in the hope that this provides both yourself and Phephisa Mabuza’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised.
I should say at this point, that in considering our replies we have again reviewed / confirmed the assurances previously provided to your Court. Each concern however has been looked at afresh, and has been cascaded to team leads.
Concern a)
“Essex Partnership University NHS Foundation Trust Crisis Response Service follows the UK Mental Health Triage scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. The scale is embedded within the 111 Triage form utilised by clinicians in their clinical decision making following a triage.
The Trust has departed from the national guidance for category D presentations such that the local guidance has been amended to reflect a 7 day response when the national guidance states 72 hours”
Response:
The Crisis Response Services (CRS) across the Trust follow the UK Mental Health Triage Scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. This form of triage scale is only used within the Crisis Response team. Whilst this guidance is not produced by NICE, it is the accepted guideline for use across the country for those organisations who offer this service.
Since CRS was started at the Trust in 2020, the scale is embedded with our 111 Triage form and offers guidance to clinicians in their clinical decision-making following a triage, however Category D has been
amended to reflect 7 days. During our investigations, the Trust was unable identify exactly why the decision was taken, however it appears to have been done to align with our community services in their operational frameworks, as the Trust embedded CRS into its services. In light of this, the senior management in the CRS and the Business Partners, have met to take forward this point. We now have clear clinical rationale frameworks, consistency, and appropriate and safe time frames for our patients coming through CRS.
Additionally work is underway in order to ensure Trust Policies align with national standards as required.
Concern b)
“Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours- same day response and do not reflect the scale on the 111 Triage form or the national guidance”.
Response:
The existing Standard Operational Policy in place is only for use by the Crisis Response Services across the Trust. It is acknowledged that the triage response times on Triage Codes D and E on the appendix were incorrectly stated as “Within 24 hours – Same Day” response, and do not reflect the scale on the form in use on the clinical system. This was owing to a typing error when the policy was completed, and that was unfortunately not picked up before the document went live. The Trust sincerely apologises for missing this, and the confusion it caused to both the Court and to the family.
The Standard Operational Policy has been reviewed and the identified errors rectified. A memo has been sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale in informing their clinical judgment in the decision making process. This has also been shared with the leads covering the other CRS teams.
I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We appreciate that there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care.
Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above.
We trust that your Court will share, as standard, a copy of this reply with Phephisa Mabuza’s family
Yours sincerel Chief Executive
Report Sections
Investigation and Inquest
On 21 March 2023 I commenced an investigation into the death of Phephisa Siphelele MABUZA. The investigation concluded at the end of an inquest held on 29th April 2024. The conclusion of the inquest was: Narrative-Phephisa Mabusa was found at the base of Dover on the morning of 14th March 2023 having died from injuries consistent with a fall from height. He was last known to be alive at 14.18 on the afternoon of 13th March 2023 when he was sighted walking alone toward the area where he was later found. He had travelled from South End on Sea to Dover by rail and had withdrawn cash on route. He had not taken olanzapine prescribed for psychosis for a number of months and was hearing voices in the days before his death but had not voiced any intention to take his own life. The evidence does not disclose how he fell or his intention at the time, but his death likely occurred on 13th March 2023 The medical cause of death was established following a post mortem to be from 1a Multiple Injuries
Circumstances of the Death
Phephisa Mabusa was diagnosed with psychotic disorder. He had been admitted to hospital as a result on a number of previous occasions, the last in July 2022 following which he was prescribed olanzapine in the community which he continued to take until the end of October 2022 when he moved out of the supported accommodation where he had been living and moved to Nottingham with his girlfriend. Phephisa had been under the care of the Essex mental health team but was discharged from their service because of his move out of the county. His care co-ordinator advised him to register with a new general practitioner so his olanzapine prescription could continue and so that the mental health team could advise the new General practitioner of Phephisa's contact with the Essex Mental Health Services. Whilst he registered with a general practitioner, he did not request a prescription. He returned to Essex on 4th November 2022 and although the supported accommodation where he had been staying was available to him, he decided together with his mother that he should get a job and get his own place rather than live in supported accommodation. He moved in with his mother. Phephisa registered with a general practitioner in the following days but did not ask for his olanzapine prescription to be restarted. His mother did not become aware that he had not been taking his medication until February 2023 when she noticed that symptoms her son started to have when in the early stages of psychosis appeared to have returned. She called his general practitioner on 3rd March 2023 but was not available when the GP called back. She made further attempts to contact his general practitioner on 7th March 2023, but on this occasion did not receive a response and therefore on 10th March 2023 rang the 111 service where she spoke to a mental health nurse who conducted a telephone triage speaking to both Phephisa and his mother. The mental health nurse’s conversation with Phephisa was very brief because Phephisa reported being tired. The mental health nurse contacted the first response team to make a face to face appointment with Phephisa and also requested his general practitioner reconsider prescribing olanzapine again. A prescription was sent electronically to the pharmacy, but the spine system disconnected and the prescription request would not go through. The prescription was therefore not available for sorry, the prescription was not therefore available for collection on 13th March 2024, when Phephisa's mother went to collect it. She did not see her son again and reported him missing when she returned from work the following day. Phephisa's death had been reported to Kent Police 10 minutes before he was reported missing to Essex Police.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.