Scott Donoghue
PFD Report
All Responded
Ref: 2023-0363
All 1 response received
· Deadline: 23 Nov 2023
Coroner's Concerns (AI summary)
Inconsistent staffing within Home Based Treatment Teams hinders patient engagement and honesty during fragile periods. Addressing this requires additional funding, recruitment, and retention to ensure continuity of care.
View full coroner's concerns
(1) It was evident that the lack of consistency in staff dealing with Mr Donoghue’s care was a factor in his ability to engage and be honest with those having oversight of him at a very fragile time in his treatment.
(2) Evidence was heard that the HBTT system is a nationwide treatment as an alternative to hospital admission and although peoples’ care in HBTT had improved, a real continuity of staff could only occur with a substantive change which would include additional funding, recruitment of appropriate staff and an ability to retain staff. I was informed that if these issues were addressed it would allow more capacity to manage consistency alongside the other demands of the service.
(3) It is worthy of note that this is the 2nd inquest heard within 3 weeks in this jurisdiction whereby inconsistency of care staff has been cited as an issue in a suicide. The other inquest was the death of a 20 year old woman.
(4) Mental Health is a rising problem and it is my understanding that 115 people die by suicide every week. Acknowledgement of the important work undertaken by HBTT and the need to give the very best support to those who have taken the, often difficult, step of seeking help with their care is a matter that requires imminent attention.
(2) Evidence was heard that the HBTT system is a nationwide treatment as an alternative to hospital admission and although peoples’ care in HBTT had improved, a real continuity of staff could only occur with a substantive change which would include additional funding, recruitment of appropriate staff and an ability to retain staff. I was informed that if these issues were addressed it would allow more capacity to manage consistency alongside the other demands of the service.
(3) It is worthy of note that this is the 2nd inquest heard within 3 weeks in this jurisdiction whereby inconsistency of care staff has been cited as an issue in a suicide. The other inquest was the death of a 20 year old woman.
(4) Mental Health is a rising problem and it is my understanding that 115 people die by suicide every week. Acknowledgement of the important work undertaken by HBTT and the need to give the very best support to those who have taken the, often difficult, step of seeking help with their care is a matter that requires imminent attention.
Responses
Action Taken
NHS England and local services have made strides in minimising staff turnover and foster effective communication and collaboration between CRHTT and Community Teams, with continuous training for CRHTT members. The government has also increased NHS spending on mental health and invested in the recruitment and retention of more mental health workers. (AI summary)
NHS England and local services have made strides in minimising staff turnover and foster effective communication and collaboration between CRHTT and Community Teams, with continuous training for CRHTT members. The government has also increased NHS spending on mental health and invested in the recruitment and retention of more mental health workers. (AI summary)
View full response
Dear Miss Harris, Thank you for your Regulation 28 report to prevent future deaths dated 28th September 2023 about the death of Mr Scott James Donoghue. I am replying as Minister with responsibility for Mental Health and Women’s Health Strategy. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Donoghue’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the lack of consistency in staff dealing with Mr Donoghue’s care and the importance of having continuity of staff which requires additional funding, recruitment of appropriate staff and an ability to retain staff at local level. I also acknowledge the important work undertaken by services such as Home-Based Treatment Teams in supporting and providing help to those in need.
In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission. Continuity of care is a top priority for NHS England and local services, and they have made significant strides in minimising staff turnover to ensure patients do not experience frequent changes in their care teams. Effective communication and collaboration between the Crisis Resolution Home Treatment Teams (CRHTT) and the Community Teams are ongoing, ensuring a seamless transition of care. Patient engagement remains at the forefront of their approach, fostering open communication to understand their needs and concerns. Continuous training and education for CRHTT members focus on identifying signs of distress and suicide risks and they are actively collaborating with other mental health and social services to offer holistic patient care with all age urgent mental health helplines in place in every area to support people in mental health crisis.
Following the last inspection of Humber Teaching Hospitals NHS Foundation Trust’s Home-Based Treatment Team in 2019, the Care Quality Commission (CQC) rated the trust as good overall. The key question ‘safe’ was rated as requires improvement. The Trust submitted an action plan to explain how it would comply with its legal obligations following the publication of the report and, in line with its usual practice, the CQC uses the information received to monitor providers of health and social care services and take appropriate regulatory action when needed.
The CQC also requested information from the trust regarding the death of Scott James Donoghue and the trust provided a copy of the serious incident investigation report on 09/02/2023. The Trust carried out its own investigation and has since developed an action plan and lessons learnt. The CQC is monitoring the implementation of this through its engagement with the trust.
The Government is expanding and transforming NHS mental health care. We recognise the wider need to increase funding, which is why between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7 billion in cash terms as compared to the target of £3.4 billion set out at the time of the NHS Long Term Plan. All integrated care boards are also on track to meet the Mental Health Investment Standard for 2023/24 so that their investment in mental health services increases in line with their overall increase in funding for that year.
The Government is also investing in the recruitment and retention of more mental health workers. As of December 2023, there were 148,951 full time equivalents, which is 33,402 more than December 2019 (a 29% increase). We are also continuing to increase our education and training commissions (across all mental health training programmes) alongside continuing to develop new roles and using existing roles to transform service delivery.
The NHS is also committed to improving access to community mental health services. By the end of 2023/24, it is expected that 370,000 more adults and older adults with severe mental health problems will have been supported within newly transformed models of care in line with the vision set out in the Community Mental Health Framework.
Finally, we published a new Suicide Prevention Strategy for England on 11 September with over 130 actions that we believe will make progress towards our ambition to reduce the suicide rate within two and a half years. As part of the Strategy, we have identified a number of groups for consideration for tailored or targeted action at a national level, including people in contact with mental health services.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission. Continuity of care is a top priority for NHS England and local services, and they have made significant strides in minimising staff turnover to ensure patients do not experience frequent changes in their care teams. Effective communication and collaboration between the Crisis Resolution Home Treatment Teams (CRHTT) and the Community Teams are ongoing, ensuring a seamless transition of care. Patient engagement remains at the forefront of their approach, fostering open communication to understand their needs and concerns. Continuous training and education for CRHTT members focus on identifying signs of distress and suicide risks and they are actively collaborating with other mental health and social services to offer holistic patient care with all age urgent mental health helplines in place in every area to support people in mental health crisis.
Following the last inspection of Humber Teaching Hospitals NHS Foundation Trust’s Home-Based Treatment Team in 2019, the Care Quality Commission (CQC) rated the trust as good overall. The key question ‘safe’ was rated as requires improvement. The Trust submitted an action plan to explain how it would comply with its legal obligations following the publication of the report and, in line with its usual practice, the CQC uses the information received to monitor providers of health and social care services and take appropriate regulatory action when needed.
The CQC also requested information from the trust regarding the death of Scott James Donoghue and the trust provided a copy of the serious incident investigation report on 09/02/2023. The Trust carried out its own investigation and has since developed an action plan and lessons learnt. The CQC is monitoring the implementation of this through its engagement with the trust.
The Government is expanding and transforming NHS mental health care. We recognise the wider need to increase funding, which is why between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7 billion in cash terms as compared to the target of £3.4 billion set out at the time of the NHS Long Term Plan. All integrated care boards are also on track to meet the Mental Health Investment Standard for 2023/24 so that their investment in mental health services increases in line with their overall increase in funding for that year.
The Government is also investing in the recruitment and retention of more mental health workers. As of December 2023, there were 148,951 full time equivalents, which is 33,402 more than December 2019 (a 29% increase). We are also continuing to increase our education and training commissions (across all mental health training programmes) alongside continuing to develop new roles and using existing roles to transform service delivery.
The NHS is also committed to improving access to community mental health services. By the end of 2023/24, it is expected that 370,000 more adults and older adults with severe mental health problems will have been supported within newly transformed models of care in line with the vision set out in the Community Mental Health Framework.
Finally, we published a new Suicide Prevention Strategy for England on 11 September with over 130 actions that we believe will make progress towards our ambition to reduce the suicide rate within two and a half years. As part of the Strategy, we have identified a number of groups for consideration for tailored or targeted action at a national level, including people in contact with mental health services.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
Response Status
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56-Day Deadline
23 Nov 2023
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 27th May 2022 I commenced an investigation into the death of Scott James DONOGHUE, aged 33 years. The investigation concluded at the end of the inquest on 28th September 2023. The conclusion of the inquest was Suicide.
Box 3 of the record of inquest read: Scott James DONOGHUE had a history of anxiety but in 2022 developed depression. He came under the care of the Home Based Mental Health Team (HBTT) following visiting the Humber Bridge with a wish to end his life on 7th May 2022. Mr Donoghue agreed to engage with HBTT and was awaiting an arranged handover to the Community Team. During this period, Mr Donoghue raised his concern at the lack of continuity of staff that were assigned to oversee his care plan. He specifically told HBTT that he would sometimes put on a front with new faces to make him look okay when he was struggling. The lack of continuity more than minimally hindered his ability to engage and receive the best level of care. On 24th May 2022,
He was 33 years of age.
His medical cause of death was recorded as: 1a Hanging
Box 3 of the record of inquest read: Scott James DONOGHUE had a history of anxiety but in 2022 developed depression. He came under the care of the Home Based Mental Health Team (HBTT) following visiting the Humber Bridge with a wish to end his life on 7th May 2022. Mr Donoghue agreed to engage with HBTT and was awaiting an arranged handover to the Community Team. During this period, Mr Donoghue raised his concern at the lack of continuity of staff that were assigned to oversee his care plan. He specifically told HBTT that he would sometimes put on a front with new faces to make him look okay when he was struggling. The lack of continuity more than minimally hindered his ability to engage and receive the best level of care. On 24th May 2022,
He was 33 years of age.
His medical cause of death was recorded as: 1a Hanging
Circumstances of the Death
Mr Donoghue was an intelligent and high achieving individual who was part of a loving relationship. He had a history of anxiety but developed depression following the loss of his mother through suicide in January 2022, some childhood issues and frustrations over the care of his young poorly daughter. He had made previous attempts to end his life including using a ligature 4 years previously, an overdose on 28/02/2022, overdose attempts in April 2022.
On 7th May 2022 Mr Donoghue was taken by police to Miranda House (a place of support for mental health) after he attended the Humber Bridge with the intention to end his life. Mr Donoghue indicated to staff at Miranda House that he wanted help; he was assessed, did not want admission and opted for being treated by the Home Based Treatment Team (HBTT).
During May 2022 Scott spoke about hanging himself to his partner,
.
The HBTT conducted a series of visits while he awaited a date to be moved to the Community Mental Health Team where he would have had one person having oversight of his care.
Due to the need for 24 hour a day/7 days a week HBTT service, the court heard that continuity of care by either one person or a small group of people was not possible. Mr Donoghue raised concerns on more than one occasion about the lack of continuity of the people overseeing his care, he specifically told them that he could sometimes put on a front with new faces to make him look okay when he was actually struggling.
Mr Donoghue used a ligature and hanged himself at his home on 24th May 2022.
On 7th May 2022 Mr Donoghue was taken by police to Miranda House (a place of support for mental health) after he attended the Humber Bridge with the intention to end his life. Mr Donoghue indicated to staff at Miranda House that he wanted help; he was assessed, did not want admission and opted for being treated by the Home Based Treatment Team (HBTT).
During May 2022 Scott spoke about hanging himself to his partner,
.
The HBTT conducted a series of visits while he awaited a date to be moved to the Community Mental Health Team where he would have had one person having oversight of his care.
Due to the need for 24 hour a day/7 days a week HBTT service, the court heard that continuity of care by either one person or a small group of people was not possible. Mr Donoghue raised concerns on more than one occasion about the lack of continuity of the people overseeing his care, he specifically told them that he could sometimes put on a front with new faces to make him look okay when he was actually struggling.
Mr Donoghue used a ligature and hanged himself at his home on 24th May 2022.
Copies Sent To
who in my opinion should receive it
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. [DATE] [SIGNED BY CORONER]
28th September 2023 Lorraine Harris
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.