Mark Kinzley
PFD Report
Partially Responded
Ref: 2024-0168
Coroner's Concerns (AI summary)
Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite a history of self-harm and deteriorating mental state contributed to the death of a vulnerable adult.
View full coroner's concerns
1. I have doubts that the location of Mr Kinzley’s care was appropriate. Mr Kinzley was a socially isolated adult suffering from a profound neurological disorder and mental illness.
2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests.
3. During the same period, Mr Kinzley was not referred for a mental health assessment despite.
a. His history of mental illness.
b. His history of deliberate self-harm.
c. His history of accidental self-harm when agitated.
d. His deteriorating mental state during the month prior to his death.
2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests.
3. During the same period, Mr Kinzley was not referred for a mental health assessment despite.
a. His history of mental illness.
b. His history of deliberate self-harm.
c. His history of accidental self-harm when agitated.
d. His deteriorating mental state during the month prior to his death.
Responses
Action Planned
NELFT Redbridge Council confirms adult placements are based on an assessment of the individual's needs prior to placement, and they will deliver targeted training to care providers regarding safeguarding, escalation processes/and risk identification within 6 months. (AI summary)
NELFT Redbridge Council confirms adult placements are based on an assessment of the individual's needs prior to placement, and they will deliver targeted training to care providers regarding safeguarding, escalation processes/and risk identification within 6 months. (AI summary)
View full response
R28 C Merchant 08/05/2024 Concern raised by the coroner Background information and supportive evidence Action By When
1. I have doubts that the location of Mr Kinzley’s care was appropriate. Mr Kinzley was a socially isolated adult suffering from a profound neurological disorder and mental illness. The Nursing Placement was arranged and facilitated via the Discharge to Assess hospital pathway and the provider identified as suitable to meet his care and support needs. Once placed a further review was undertaken and in Feb 2023, a referral was completed for an Independent Mental Capacity Advocate (IMCA) a Mental Capacity Assessment completed, and a referral was made to Occupational Therapy Services. From our records there are no concerns raised by the OT, SW or IMCA relating to the suitability or otherwise of the placement. The Local Authority records confirm that the outcome of the IMCA involvement (as requested by Cranbrook and Loxford Locality HASS) was that it was in Mr Kinzley’s best interest to remain long-term in his current placement where he remained up until his tragic death. The care home advised that they were able to continue to meet his needs. Mr Kinzley stated (as part of his review), that although he did not want to remain in his current placement, he did not want to move anywhere else and that he is being cared for in his current place. Mr Kinzley was scheduled for an annual Adult Social Care Review in February 2024 (unless notified by the care home of any significant changes in his presentation or care and treatment needs). All adult placements are based on an assessment of the individual’s needs prior to placement. Completed
R28 C Merchant 08/05/2024
2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests. Mr Kinzley was formally assessed by both duly qualified and authorised BIA and S12 doctor (05/07/2023) following an application by the Care Home for a DoLS authorisation given the level of restrictions placed upon him with his care and treatment in the accommodation. Both agreed he lacked capacity regarding matters relating to his accommodation, care and treatment at the care home. A recommendation was made for the maximum permissible duration of an authorisation of 12 months. As part of the DoLS procedure Mr Kinzley had access to an advocate (Independent Mental Capacity Advocate (IMCA) and the IMCA was consulted with by the Best Interest Assessor given Mr Kinzley’s lack of capacity. The IMCA hereby acting as his voice regarding considerations of his best interests regarding accommodation, care and treatment. BIA/S12 doctor and IMCA Completed
3. During the same period, Mr Kinzley was not referred for a mental health assessment despite:
a. His history of mental illness.
b. His history of deliberate self-harm.
c. His history of accidental self-harm when agitated.
d. His deteriorating mental state during the month prior to his death. From the enquiries we understand the Cambridge Nursing home staff identified that MK was at risk of self- harm and referred to his GP in October 2023 following the usual process. The Local Authority were not notified of any changes to Mr Mark Kinzley’s mental health during his stay at Cambridge Nursing Home. The Local Authority will deliver targeted training to care providers regarding safeguarding, escalation processes/an d risk identification. It will be emphasised to all providers that if there is any indication there is evidence of a risk of self- 6 months from date of submission
R28 C Merchant 08/05/2024 . harm or other harm to health, that the Local Authority is informed at the same time as the health professionals and an appropriate safeguarding notification made to the First Contact Team.
1. I have doubts that the location of Mr Kinzley’s care was appropriate. Mr Kinzley was a socially isolated adult suffering from a profound neurological disorder and mental illness. The Nursing Placement was arranged and facilitated via the Discharge to Assess hospital pathway and the provider identified as suitable to meet his care and support needs. Once placed a further review was undertaken and in Feb 2023, a referral was completed for an Independent Mental Capacity Advocate (IMCA) a Mental Capacity Assessment completed, and a referral was made to Occupational Therapy Services. From our records there are no concerns raised by the OT, SW or IMCA relating to the suitability or otherwise of the placement. The Local Authority records confirm that the outcome of the IMCA involvement (as requested by Cranbrook and Loxford Locality HASS) was that it was in Mr Kinzley’s best interest to remain long-term in his current placement where he remained up until his tragic death. The care home advised that they were able to continue to meet his needs. Mr Kinzley stated (as part of his review), that although he did not want to remain in his current placement, he did not want to move anywhere else and that he is being cared for in his current place. Mr Kinzley was scheduled for an annual Adult Social Care Review in February 2024 (unless notified by the care home of any significant changes in his presentation or care and treatment needs). All adult placements are based on an assessment of the individual’s needs prior to placement. Completed
R28 C Merchant 08/05/2024
2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests. Mr Kinzley was formally assessed by both duly qualified and authorised BIA and S12 doctor (05/07/2023) following an application by the Care Home for a DoLS authorisation given the level of restrictions placed upon him with his care and treatment in the accommodation. Both agreed he lacked capacity regarding matters relating to his accommodation, care and treatment at the care home. A recommendation was made for the maximum permissible duration of an authorisation of 12 months. As part of the DoLS procedure Mr Kinzley had access to an advocate (Independent Mental Capacity Advocate (IMCA) and the IMCA was consulted with by the Best Interest Assessor given Mr Kinzley’s lack of capacity. The IMCA hereby acting as his voice regarding considerations of his best interests regarding accommodation, care and treatment. BIA/S12 doctor and IMCA Completed
3. During the same period, Mr Kinzley was not referred for a mental health assessment despite:
a. His history of mental illness.
b. His history of deliberate self-harm.
c. His history of accidental self-harm when agitated.
d. His deteriorating mental state during the month prior to his death. From the enquiries we understand the Cambridge Nursing home staff identified that MK was at risk of self- harm and referred to his GP in October 2023 following the usual process. The Local Authority were not notified of any changes to Mr Mark Kinzley’s mental health during his stay at Cambridge Nursing Home. The Local Authority will deliver targeted training to care providers regarding safeguarding, escalation processes/an d risk identification. It will be emphasised to all providers that if there is any indication there is evidence of a risk of self- 6 months from date of submission
R28 C Merchant 08/05/2024 . harm or other harm to health, that the Local Authority is informed at the same time as the health professionals and an appropriate safeguarding notification made to the First Contact Team.
Action Taken
Evergreen Surgery has provided training to all clinicians on how to complete Mental Capacity Assessments. They are arranging for VoiceAbility to provide training on advocacy services. The surgery has started asking newly registered patients for information about the wider determinants of health, and nursing staff at the nursing home are providing the ABC behaviour chart to the clinician on the care home round if they have concerns about a patient's behaviour. (AI summary)
Evergreen Surgery has provided training to all clinicians on how to complete Mental Capacity Assessments. They are arranging for VoiceAbility to provide training on advocacy services. The surgery has started asking newly registered patients for information about the wider determinants of health, and nursing staff at the nursing home are providing the ABC behaviour chart to the clinician on the care home round if they have concerns about a patient's behaviour. (AI summary)
View full response
Dear Mr Irvine, Response to Regula-on 28 Report following inquest into the death of Mark Wolfe Kinzley We write to acknowledge receipt of the Regula:on 28 report ('the Report’) dated 26 March 2024 concerning the tragic death of Mr Mark Wolfe Kinzley. Firstly, we extend our deepest condolences to the family of Mr Kinzley. As a Surgery, we were shocked and saddened to learn of Mr Kinzley's death. His death has deeply affected us, and we are commiPed to learning to prevent such tragedies in the future. Regarding the concerns outlined in the Report, we would like to provide the following clarifica:ons and addi:onal ac:ons taken by the Surgery:
1. Appropriateness of the Nursing Home: We acknowledge the concerns regarding the suitability of the nursing home for Mr Kinzley's needs. We understand that his care needs were assessed by the appropriate agencies and Mr Kinzley consented to the placement in Cambridge Nursing Home. We wish to clarify that the Surgery does not have authority over the placement decisions of individuals in nursing homes. Likewise, the Surgery would not be involved in the assessment of placement suitability.
On the 26 October 2023, one of our clinicians, , reviewed Mr Kinzley. Mr Kinzley declined any support from at this :me regarding his physical or mental health. AZer this consulta:on, discussed with the care home nursing staff about considering whether Mr Kinzley’s placement needed to be reviewed by the appropriate agencies.
2 We would like to take this opportunity to assure you that all our clinicians have appropriate safeguarding training and that the Surgery staff would raise safeguarding alerts if there were concerns about the care being provided by a care home.
2. Capacity Assessments: We understand that this concern relates to Mr Kinzley not having a formal capacity assessment undertaken and documented and not having the appointment of an advocate.
Our clinical staff conducted mul:ple assessments of Mr Kinzley's capacity during his interac:ons with our Surgery. Capacity assessments are ques:on and :me specific. At the :me of Mr Kinzley’s assessments by our clinicians, he was deemed to have capacity. There are various decisions that Mr Kinzley made regarding his physical and mental health detailed in the medical record. We detail these below:
On 12 Jan 2023 consent was obtained from Mr Kinzley to refer him to the neurology service regarding his cerebellar ataxia. On 27 April 2023, Mr Kinzley consented to a referral to the ‘first fit’ (seizure) clinic. On 7 September 2023, the surgery received a request to complete a best interest decision to give Mr Kinzley the COVID-19 vaccina:on. This request was received as part of a request for authorisa:on for mul:ple residents of the home. One of our clinicians has commented in the medical record at the :me that Mr Kinzley had previously refused this vaccina:on and that our clinician felt he had capacity to make decisions about this. Our clinician reviewed this with Mr Kinzley on 12 September 2023 and he then consented to receiving the COVID-19 and influenza vaccina:on.
Regarding his mental health, on the 16 March 2023, Mr Kinzley was assessed with regard to anxiety and agita:on. He was offered medica:on and he declined this. Similarly, on the 1 August 2023, Mr Kinzley was assessed by regarding erra:c behaviour. It was felt that this behaviour could be related to anxiety. Mr Kinzley declined any medica:on for this. On the 26 October, he was calm but had shown erra:c behaviour in the preceding days. Mr Kinzley declined any form of support from the Surgery. At the :me of these consulta:ons, there was no evidence that Mr Kinzley did not have capacity to make the decisions he did about his care.
We have noted that there is no documenta:on that a referral to mental health services was offered. We have reflected as a Surgery that it is important to document in the medical record all of the management op:ons discussed with a pa:ent.
At the Surgery’s last consulta:on with Mr Kinzley, was informed by the nursing staff (who are also capable of capacity assessments) that Mr Kinzley had capacity. During this consulta:on and assessment of Mr Kinzley, there was no indica:on that Mr Kinzley lacked capacity or needed further formal assessment of his capacity.
3 Independent of the Surgery assessments, Mr Kinzley had a Depriva:on of Liberty safeguarding (DOLS) assessment (circa July 2023) aZer he was prescribed an emergency medica:on to be used if Mr Kinzley had a prolonged seizure. If he did have a seizure, by defini:on, he would not have capacity to make decisions about his care and this medica:on would be indicated in his best interest. It is our understanding that the DOLS assessment should include an assessment of capacity to make decisions. We remain unaware of this assessment outcome.
We do consider Mr Kinzley’s past medical history to be significant and in future, we will endeavour to encourage pa:ents to follow the medical advice whilst respec:ng their autonomy to make their own decisions. We recognise that Mr Kinzley was socially isolated despite living in a nursing home. We agree that support from a next of kin or advocate can oZen help pa:ents make decisions about their own care. We have taken steps as a prac:ce to iden:fy and help pa:ents who we iden:fy as not having such support, which we explain in more detail later.
This case has been formally discussed with the whole clinical team at a surgery wide clinical governance mee:ng on the 23 April 2024. We have a weekly prac:ce mee:ng as a forum to discuss cases and pa:ent care. At the governance mee:ng we agreed that clinicians would bring any similar cases to the weekly mee:ng to discuss them with the wider team to support gefng a collec:ve opinion on the case. Individual cases could also be discussed at the monthly care home mul:disciplinary team (MDT) mee:ng that the Surgery is a member of. The care home MDT is a mee:ng between local health agencies (GP, Geriatricians, Mental Health Services) and local care homes focusing on learning specific to care home pa:ents care and also an opportunity to discuss individual cases.
We have also agreed that in any similar cases in future, we would formally document the capacity assessment. At our next prac:ce Governance mee:ng (23 July 2024), we are providing an educa:onal session to the whole clinical team on capacity assessments, with a par:cular focus on more complex capacity assessments.
3. Referral to Mental Health Services: Whilst we recognise the importance of mental health assessments and referrals for individuals with a history of mental health issues, we emphasise that any referral to mental health services in this situa:on would have required Mr. Kinzley's consent. He was deemed to have capacity at the :mes he was assessed, and therefore any referral would have been con:ngent upon his willingness to consent to such services.
Following the inquest, our named clinician, Dr Barker, for the care home has made the care staff aware that the local mental health teams, also accept referrals from pa:ents, carers, and other medical professionals, in addi:on to referrals from a GP. This may be appropriate for any future cases as it would allow the care home to make a referral without wai:ng for a GP assessment, such as pa:ents with fluctua:ng capacity or emergency situa:ons.
4
In our wider Surgery prac:ce, we regularly share mental health crisis support details with a pa:ent's next of kin or rela:ve, provided we have the pa:ent's consent. Since the inquest, we have updated our Surgery text message that we send to pa:ents and their next of kin. Previously, it included informa:on about talking therapy services and crisis support. Now, it offers more comprehensive details about the various mental health services available in Redbridge and how pa:ents can access them. This updated message also serves as a readily accessible reference resource for clinicians when needed.
We would also like to take this opportunity to highlight the following further ac:ons taken by our Surgery since the inquest:
• Any new registered pa:ent that resides in a care home already has an ini:al formal comprehensive assessment by our clinician within a week of registra:on. We use the Comprehensive Geriatric Assessment (CGA) as a template for this. This is a holis:c assessment of the health and wellbeing of an individual, with formula:on of a care plan addressing any needs iden:fied. We have agreed at the Surgery Governance mee:ng that all care home pa:ents at this assessment would also be specifically assessed for social isola:on. We have agreed that this would include iden:fying if they have a next of kin, rela:ve or someone else they would like to be involved in their care. This will then be documented in their care plan. If there is concern around social isola:on, more support could then be provided. The support can be tailored to the needs of the individual and this could include referral to befriending services (a support program that connects volunteers with individuals who are lonely or socially isolated) or more formal advocacy service.
• We have agreed that our Surgery’s social prescriber could be more involved with our care home pa:ents. We recognise that this may help to support pa:ents in the future who are iden:fied as being socially isolated. Our social prescriber has access to various support services including the befriending services men:oned above.
• We have contacted and arranged for VoiceAbility, who provide formal and more general advocacy services in Redbridge, to come and speak to the Surgery team about the services they offer and how they can help us with the care of our pa:ents. VoiceAbility are running this training session for the Surgery on the 10 June 2024.
• Wider determinants of health – the wider determinants of health are a diverse range of social, economic, and environmental factors which influence people’s mental and physical health. The surgery has recently started asking newly registered pa:ents for informa:on about this to support the care we provide them. We are looking to expand this to all our currently registered pa:ents in the near future.
• We have asked that nursing staff at the nursing home provide the ABC behaviour chart to the clinician on the care home round if they have concerns about a pa:ent's behaviour. The ABC behaviour chart is an observa:on tool that helps to detail and understand the causes of certain behaviours. It records what happened before, during and aZer episodes of par:cular behaviours. This will allow our
5 clinicians to have more detailed informa:on about any behaviour allowing prompt assessment and appropriate interven:on.
• We will be sharing this case and our learning with our Primary Care Network (the collec:on of 11 prac:ces in Wanstead and Woodford) and care home mul:disciplinary mee:ng (MDT) to support wider learning and discussion among healthcare professionals. The date of this is not yet confirmed but discussions are taking place with the appropriate individuals to facilitate this in the near future.
In conclusion, we would like to assure you that we take the concerns raised in the report seriously and are commiPed to pa:ent safety and providing the best medical care to our pa:ents. Please do not hesitate to contact us if you require any further informa:on or clarifica:on about our response.
1. Appropriateness of the Nursing Home: We acknowledge the concerns regarding the suitability of the nursing home for Mr Kinzley's needs. We understand that his care needs were assessed by the appropriate agencies and Mr Kinzley consented to the placement in Cambridge Nursing Home. We wish to clarify that the Surgery does not have authority over the placement decisions of individuals in nursing homes. Likewise, the Surgery would not be involved in the assessment of placement suitability.
On the 26 October 2023, one of our clinicians, , reviewed Mr Kinzley. Mr Kinzley declined any support from at this :me regarding his physical or mental health. AZer this consulta:on, discussed with the care home nursing staff about considering whether Mr Kinzley’s placement needed to be reviewed by the appropriate agencies.
2 We would like to take this opportunity to assure you that all our clinicians have appropriate safeguarding training and that the Surgery staff would raise safeguarding alerts if there were concerns about the care being provided by a care home.
2. Capacity Assessments: We understand that this concern relates to Mr Kinzley not having a formal capacity assessment undertaken and documented and not having the appointment of an advocate.
Our clinical staff conducted mul:ple assessments of Mr Kinzley's capacity during his interac:ons with our Surgery. Capacity assessments are ques:on and :me specific. At the :me of Mr Kinzley’s assessments by our clinicians, he was deemed to have capacity. There are various decisions that Mr Kinzley made regarding his physical and mental health detailed in the medical record. We detail these below:
On 12 Jan 2023 consent was obtained from Mr Kinzley to refer him to the neurology service regarding his cerebellar ataxia. On 27 April 2023, Mr Kinzley consented to a referral to the ‘first fit’ (seizure) clinic. On 7 September 2023, the surgery received a request to complete a best interest decision to give Mr Kinzley the COVID-19 vaccina:on. This request was received as part of a request for authorisa:on for mul:ple residents of the home. One of our clinicians has commented in the medical record at the :me that Mr Kinzley had previously refused this vaccina:on and that our clinician felt he had capacity to make decisions about this. Our clinician reviewed this with Mr Kinzley on 12 September 2023 and he then consented to receiving the COVID-19 and influenza vaccina:on.
Regarding his mental health, on the 16 March 2023, Mr Kinzley was assessed with regard to anxiety and agita:on. He was offered medica:on and he declined this. Similarly, on the 1 August 2023, Mr Kinzley was assessed by regarding erra:c behaviour. It was felt that this behaviour could be related to anxiety. Mr Kinzley declined any medica:on for this. On the 26 October, he was calm but had shown erra:c behaviour in the preceding days. Mr Kinzley declined any form of support from the Surgery. At the :me of these consulta:ons, there was no evidence that Mr Kinzley did not have capacity to make the decisions he did about his care.
We have noted that there is no documenta:on that a referral to mental health services was offered. We have reflected as a Surgery that it is important to document in the medical record all of the management op:ons discussed with a pa:ent.
At the Surgery’s last consulta:on with Mr Kinzley, was informed by the nursing staff (who are also capable of capacity assessments) that Mr Kinzley had capacity. During this consulta:on and assessment of Mr Kinzley, there was no indica:on that Mr Kinzley lacked capacity or needed further formal assessment of his capacity.
3 Independent of the Surgery assessments, Mr Kinzley had a Depriva:on of Liberty safeguarding (DOLS) assessment (circa July 2023) aZer he was prescribed an emergency medica:on to be used if Mr Kinzley had a prolonged seizure. If he did have a seizure, by defini:on, he would not have capacity to make decisions about his care and this medica:on would be indicated in his best interest. It is our understanding that the DOLS assessment should include an assessment of capacity to make decisions. We remain unaware of this assessment outcome.
We do consider Mr Kinzley’s past medical history to be significant and in future, we will endeavour to encourage pa:ents to follow the medical advice whilst respec:ng their autonomy to make their own decisions. We recognise that Mr Kinzley was socially isolated despite living in a nursing home. We agree that support from a next of kin or advocate can oZen help pa:ents make decisions about their own care. We have taken steps as a prac:ce to iden:fy and help pa:ents who we iden:fy as not having such support, which we explain in more detail later.
This case has been formally discussed with the whole clinical team at a surgery wide clinical governance mee:ng on the 23 April 2024. We have a weekly prac:ce mee:ng as a forum to discuss cases and pa:ent care. At the governance mee:ng we agreed that clinicians would bring any similar cases to the weekly mee:ng to discuss them with the wider team to support gefng a collec:ve opinion on the case. Individual cases could also be discussed at the monthly care home mul:disciplinary team (MDT) mee:ng that the Surgery is a member of. The care home MDT is a mee:ng between local health agencies (GP, Geriatricians, Mental Health Services) and local care homes focusing on learning specific to care home pa:ents care and also an opportunity to discuss individual cases.
We have also agreed that in any similar cases in future, we would formally document the capacity assessment. At our next prac:ce Governance mee:ng (23 July 2024), we are providing an educa:onal session to the whole clinical team on capacity assessments, with a par:cular focus on more complex capacity assessments.
3. Referral to Mental Health Services: Whilst we recognise the importance of mental health assessments and referrals for individuals with a history of mental health issues, we emphasise that any referral to mental health services in this situa:on would have required Mr. Kinzley's consent. He was deemed to have capacity at the :mes he was assessed, and therefore any referral would have been con:ngent upon his willingness to consent to such services.
Following the inquest, our named clinician, Dr Barker, for the care home has made the care staff aware that the local mental health teams, also accept referrals from pa:ents, carers, and other medical professionals, in addi:on to referrals from a GP. This may be appropriate for any future cases as it would allow the care home to make a referral without wai:ng for a GP assessment, such as pa:ents with fluctua:ng capacity or emergency situa:ons.
4
In our wider Surgery prac:ce, we regularly share mental health crisis support details with a pa:ent's next of kin or rela:ve, provided we have the pa:ent's consent. Since the inquest, we have updated our Surgery text message that we send to pa:ents and their next of kin. Previously, it included informa:on about talking therapy services and crisis support. Now, it offers more comprehensive details about the various mental health services available in Redbridge and how pa:ents can access them. This updated message also serves as a readily accessible reference resource for clinicians when needed.
We would also like to take this opportunity to highlight the following further ac:ons taken by our Surgery since the inquest:
• Any new registered pa:ent that resides in a care home already has an ini:al formal comprehensive assessment by our clinician within a week of registra:on. We use the Comprehensive Geriatric Assessment (CGA) as a template for this. This is a holis:c assessment of the health and wellbeing of an individual, with formula:on of a care plan addressing any needs iden:fied. We have agreed at the Surgery Governance mee:ng that all care home pa:ents at this assessment would also be specifically assessed for social isola:on. We have agreed that this would include iden:fying if they have a next of kin, rela:ve or someone else they would like to be involved in their care. This will then be documented in their care plan. If there is concern around social isola:on, more support could then be provided. The support can be tailored to the needs of the individual and this could include referral to befriending services (a support program that connects volunteers with individuals who are lonely or socially isolated) or more formal advocacy service.
• We have agreed that our Surgery’s social prescriber could be more involved with our care home pa:ents. We recognise that this may help to support pa:ents in the future who are iden:fied as being socially isolated. Our social prescriber has access to various support services including the befriending services men:oned above.
• We have contacted and arranged for VoiceAbility, who provide formal and more general advocacy services in Redbridge, to come and speak to the Surgery team about the services they offer and how they can help us with the care of our pa:ents. VoiceAbility are running this training session for the Surgery on the 10 June 2024.
• Wider determinants of health – the wider determinants of health are a diverse range of social, economic, and environmental factors which influence people’s mental and physical health. The surgery has recently started asking newly registered pa:ents for informa:on about this to support the care we provide them. We are looking to expand this to all our currently registered pa:ents in the near future.
• We have asked that nursing staff at the nursing home provide the ABC behaviour chart to the clinician on the care home round if they have concerns about a pa:ent's behaviour. The ABC behaviour chart is an observa:on tool that helps to detail and understand the causes of certain behaviours. It records what happened before, during and aZer episodes of par:cular behaviours. This will allow our
5 clinicians to have more detailed informa:on about any behaviour allowing prompt assessment and appropriate interven:on.
• We will be sharing this case and our learning with our Primary Care Network (the collec:on of 11 prac:ces in Wanstead and Woodford) and care home mul:disciplinary mee:ng (MDT) to support wider learning and discussion among healthcare professionals. The date of this is not yet confirmed but discussions are taking place with the appropriate individuals to facilitate this in the near future.
In conclusion, we would like to assure you that we take the concerns raised in the report seriously and are commiPed to pa:ent safety and providing the best medical care to our pa:ents. Please do not hesitate to contact us if you require any further informa:on or clarifica:on about our response.
Sent To
Response Status
Linked responses
2 of 4
56-Day Deadline
22 May 2024
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Chief Coroner's Non-Response List
The Chief Coroner has confirmed that the following organisation did not respond within the required period:
The Cambridge Nursing Home Ltd, Wanstead
Report Sections
Investigation and Inquest
On 9th November 2023 this court commenced an investigation into the death of Mark Wolfe Kinzley aged 61 years. The investigation concluded at the end of the inquest on 26th March 2024. The court returned a narrative conclusion. “Mark Wolfe Kinzley died in hospital on 1st November 2023 due to complications of injuries sustained on 30th October 2023 in his nursing home when he suspended himself from a ligature . It has not been possible to determine his intentions at the time of the suspension.”
Mr Kinzley’s medical cause of death was determined as;
1a Hypoxic-ischaemic brain damage 1b Asphyxia
Mr Kinzley’s medical cause of death was determined as;
1a Hypoxic-ischaemic brain damage 1b Asphyxia
Circumstances of the Death
Mark Wolfe Kinzley was a frail 61 yr old man who suffered from a neurological disorder, Dandy-Walker Syndrome. This congenital disorder presented itself in symptoms of cerebellar ataxia which limited his mobility, speech and continence. Mr Kinzley had recently developed seizure activity.
Mr Kinzley had a history of mental health problems having been diagnosed with anxiety and depression. On at least two previous occasions Mr Kinzley had attempted self-harm by overdose, on one of those occasions he was admitted for inpatient mental health treatment.
Mr Kinzley was known to have periodic episodes of aggressive and irritable behaviour, marked by utterances of frustration and accidental self-harm due to high-risk behaviours.
In January of 2023 following a hospital admission due to physical symptoms of self-neglect, Mr Kinzley was discharged to a nursing home funded by the local authority. The nursing home was typically occupied by elderly persons receiving end of life care.
Concerns lay as to the extent of Mr Kinzley’s capacity and a DOLS (deprivation of liberty standards) order had been applied for, but not finalised with the local authority.
Mr Kinzley was socially isolated, during his 10-month residence at the nursing home he received neither a visit nor a telephone call from a relative or friend.
In the months leading to Mr Kinzley’s death he was noted by carers at the nursing home to have experienced episodes of agitation at an increased level of frequency and acuity. Mark was observed on multiple occasions to be “sad”,” agitated”,” angry” & “trying to hit/injure self”. These episodes accelerated in the week prior to his death.
On the morning of 30th October 2023 he was found unresponsive in his bedroom, suspended by a coat hanger around his neck, attached to his door handle. Despite the best efforts of carers and the emergency services he later died in hospital from his injuries.
Mr Kinzley had a history of mental health problems having been diagnosed with anxiety and depression. On at least two previous occasions Mr Kinzley had attempted self-harm by overdose, on one of those occasions he was admitted for inpatient mental health treatment.
Mr Kinzley was known to have periodic episodes of aggressive and irritable behaviour, marked by utterances of frustration and accidental self-harm due to high-risk behaviours.
In January of 2023 following a hospital admission due to physical symptoms of self-neglect, Mr Kinzley was discharged to a nursing home funded by the local authority. The nursing home was typically occupied by elderly persons receiving end of life care.
Concerns lay as to the extent of Mr Kinzley’s capacity and a DOLS (deprivation of liberty standards) order had been applied for, but not finalised with the local authority.
Mr Kinzley was socially isolated, during his 10-month residence at the nursing home he received neither a visit nor a telephone call from a relative or friend.
In the months leading to Mr Kinzley’s death he was noted by carers at the nursing home to have experienced episodes of agitation at an increased level of frequency and acuity. Mark was observed on multiple occasions to be “sad”,” agitated”,” angry” & “trying to hit/injure self”. These episodes accelerated in the week prior to his death.
On the morning of 30th October 2023 he was found unresponsive in his bedroom, suspended by a coat hanger around his neck, attached to his door handle. Despite the best efforts of carers and the emergency services he later died in hospital from his injuries.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.