Edward Rhodes
PFD Report
All Responded
Ref: 2023-0280
All 1 response received
· Deadline: 26 Sep 2023
Coroner's Concerns (AI summary)
There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely on verbal discussions without an automatic referral system or written confirmation, leading to unmet care.
View full coroner's concerns
1. During the inquest evidence was heard that: i. Mr Rhodes wanted to address the underlying causes for his addiction. He wished to be referred to the Mental Health Team for an assessment. He was told by medical professionals that he needed to be 90 days sober.
ii. Mr Rhodes saw his GP and it was confirmed during evidence that a referral would be made by the GP after a period of 90 days abstinence.
iii. Mr Rhodes’ GP explained that in order to make a referral Mr Rhodes had to make a specific appointment to discuss the Mental Health referral. The GP said that Mr Rhodes was aware of this.
iv. Mr Rhodes saw his GP on 14/10/22 (at that time he had been sober in excess of 90 days) for a medical condition. On that occasion there was no discussion about the Mental Health referral.
v. Mr Rhodes’ family (who were close to him and had discussions with him) gave evidence to say that his understanding was that following the 90 day period of sobriety there would be an automatic referral by his GP to the Mental Health Services.
vi. The report from the addiction support agency details entries whereby during discussion with his Recovery Worker Mr Rhodes provides a detailed chronology of his period of abstinence and the fact he was waiting to hear from the Mental Health Services for an assessment appointment.
vii. Mr Rhodes’ partner gave evidence that at the time he started to relapse he was still waiting for a date from the Mental Health Services and that he was expressing disillusionment with the Mental Health Services.
2. I have concerns with regard to the following: i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral.
ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict.
iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient.
iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient.
ii. Mr Rhodes saw his GP and it was confirmed during evidence that a referral would be made by the GP after a period of 90 days abstinence.
iii. Mr Rhodes’ GP explained that in order to make a referral Mr Rhodes had to make a specific appointment to discuss the Mental Health referral. The GP said that Mr Rhodes was aware of this.
iv. Mr Rhodes saw his GP on 14/10/22 (at that time he had been sober in excess of 90 days) for a medical condition. On that occasion there was no discussion about the Mental Health referral.
v. Mr Rhodes’ family (who were close to him and had discussions with him) gave evidence to say that his understanding was that following the 90 day period of sobriety there would be an automatic referral by his GP to the Mental Health Services.
vi. The report from the addiction support agency details entries whereby during discussion with his Recovery Worker Mr Rhodes provides a detailed chronology of his period of abstinence and the fact he was waiting to hear from the Mental Health Services for an assessment appointment.
vii. Mr Rhodes’ partner gave evidence that at the time he started to relapse he was still waiting for a date from the Mental Health Services and that he was expressing disillusionment with the Mental Health Services.
2. I have concerns with regard to the following: i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral.
ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict.
iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient.
iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient.
Responses
Action Planned
The Practice refers to the current ICB plan to improve mental health, addiction and wellbeing concerns. They also note that a summary of referral criteria will be prepared by CMHT. (AI summary)
The Practice refers to the current ICB plan to improve mental health, addiction and wellbeing concerns. They also note that a summary of referral criteria will be prepared by CMHT. (AI summary)
View full response
IN THE CORONER'S COURT FOR THE AREA OF DORSET BEFORE ASSISTANT CORONER MIDDLETON THE INQUEST TOUCHING THE DEATH OF EDWARD ENGLAND RHODES RESPONSE TO REGULATION 28 - BEAUFORT ROAD SURGERY
1. H.M. Assistant Coroner Middleton for the Coroner Area of Dorset has made a Regulation 28 Report Action to prevent deaths dated 1 August 2023 ("the Regulation 28 Report") concerning the death of Edward England Rhodes ("the Deceased"). This arises from the Inquest of 27 July 2023 ("the Inquest").
2. The Regulation 28 Report is addressed to the Practice Manager at the Beaufort Road Surgery, 21 Beaufort Road, Southboume, Bournemouth, Dorset, BH6 SAJ ("the Practice"), which is a general medical practice. This is the response of the Partners in the Practice to the Regulation 28 Report in accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013 ("the Response"). BACKGROUND
3. , is a GP Partner in the Practice.
4. H.M. Coroner for Dorset's office requested, in a letter addressed to the Practice dated 7 February 2023, "a signed statement into the medical history of the deceased and advise ofany treatment or medication you prescribed within the six months preceding his death." provided H.M. Coroner with a statement addressing the matters in accordance with this request, dated 7 March 2023.
5. Neither the Practice nor , were afforded Interested Person ("IP") status for the Inquest. The Practice and were not therefore legally represented at the Inquest and were not provided with disclosure of the Inquest Bundle. 0
6. gave evidence (virtually) at the Inquest on 27 July 2023. He was the first witness to give evidence and was discharged once his evidence had concluded. He did not hear any of the subsequent evidence and played no further part in the Inquest. There were no other attendees from/for the Practice.
PRACTICE RESPONSE TO REGULATION 28 REPORT
7. The numbering in the Regulation 28 Report is adopted. H.M. Assistant Coroner Middleton's comments/concerns are set out in italics, with the Practice's Response below: "The MATTERS OF CONCERN are as follows
1. During the inquest evidence was heard that:
i. Mr Rhodes wanted to address the underlying causes for his addiction. He wished to be referred to the Mental Health Team for an assessment. He was told by medical professionals that he needed to be 90 days sober. In respect of the first sentence the Deceased had a long-standing history of addiction. He had been a patient at the Practice from 6 February 2020, until his death. He first expressed a desire to his hepatologist (liver specialist), Dr Clare Harris, for referral to the Community Mental Health Team ("CMHT") on 16 August 2022 (having never previously expressed such a wish to the Practice). For the sake of clarity, the GPs at the Practice were not the medical professionals who first told the Deceased the information contained in the second sentence. This came from (an)other medical professional(s). Of note, the Deceased saw his hepatologist (liver specialist), , on 16 August
2022. Following which the Practice received a letter from dated 18 August 2022 and which states (our emphasis): "[the Deceased] is concerned that he may have an underlying mental health disorder that contributes to his relapses and is very keen to be seen by CMHT. However, he is aware that he needs to be completely abstinent of alcohol and recreational drugs for a period of 90 days before this referral can be made." ' letter is also marked as copied to the Deceased.
ii. Mr Rhodes saw his GP and it was confirmed during evidence that a referral would be made by the GP after a period of90 days abstinence. left after giving his evidence and neither he nor the Practice were represented at the Inquest to hear what others may have said in their evidence. does not recall giving evidence to the effect that "a referral would be made by the GP after a period of 90 days abstinence" and nor does his Statement state this. Following his consultation with his hepatologist on 16 August 2022, the relevant chronology is: 2
• The Deceased next contacted the Practice online on 22 August 2022, by e- Consult requesting an extended sick note until 31 October 2022. The Deceased stated (our emphasis): " .. . I'll be 90 days clean come 02/09/22 and I'll arrange an appointment at that time to get a CMHT referral."
• Thee-Consult was triaged and a new eMED3 (sick note) issued by on 23 August 2022.
• The Deceased attended a face to face consultation with on 14 September 2022 with an unrelated complaint. That was an urgent, same day appointment for tonsillitis. confirmed in his evidence that the Deceased did not mention nor request anything about his mental health at this consultation, he did not discuss the CMHT referral or "requirement" for 90 days abstinence during this consultation. gave evidence that the Deceased was acutely unwell from tonsilitis. The attendance was entirely unrelated and addressed only the Deceased's acute presentation with tonsillitis.
• The Deceased's next and final contact with the Practice was on 28 October 2022, again by e-Consult, seeking a sick note extension until 24 December 2022. The e-Consult was triaged and a new eMED3 (sick note) issued by the same day. The Practice were aware from ' letter and the Deceased's e-Consult message of 22 August 2022 that he was trying to achieve 90 days' abstinence. As his eConsult message of that date (set out above) clearly states, the Deceased also knew he needed to initiate the contact with the Practice for a consultation for a mental health review, in order to receive a CMHT referral if appropriate, and he planned to do this.
iii. Mr Rhodes' GP explained that in order to make a referral Mr Rhodes had to make a specific appointment to discuss the Mental Health referral. The GP said that Mr Rhodes was aware ofthis. This is correct. The response at ii above is reiterated.
iv. Mr Rhodes saw his GP on 14/10/22 (at that time he had been sober in excess of90 days) for a medical condition. On that occasion there was no discussion about the Mental Health referral. This is correct. As explained in the Response at ii above, the appointment was in respect of an unrelated, urgent presentation with tonsilitis. There was no discussion of his sobriety or CMHT referral. 3
v. Mr Rhodes 'family (who were close to him and had discussions with him) gave evidence to say that his understanding was that following the 90 day period of sobriety there would be an automatic referral by his GP to the Mental Health Services. This reflects the family's evidence of their understanding of the Deceased's belief. Response ii above is reiterated.
vi. The report from the addiction support agency details entries whereby during discussion with his Recovery Worker Mr Rhodes provides a detailed chronology of his period of abstinence and the fact he was waiting to hear from the Mental Health Services for an assessment appointment. This reflects the evidence heard.
vii. Mr Rhodes' partner gave evidence that at the time he started to relapse he was still waiting for a date from the Mental Health Services and that he was expressing disillusionment with the Mental Health Services. This reflects the evidence heard.
2. I have concerns with regard to the following:
i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral. The Practice do not accept that there was either a breakdown in communication nor miscommunication between the Practice/GPs and the Deceased. The discussion concerning the CMHT referral was between the Deceased and his hepatologist, not the GPs. The hepatologist's letter to the Practice (18 August 2022) is marked as copied to the Deceased so he would/should have had the written communication, see response to 1. ii above for details. It is evident from the Deceased's e-Consult email to the Practice on 22 August 2022, that the Deceased was aware that he himself needed to make an appointment with the Practice to discuss his mental health in order to get a CMHT referral. As the Deceased clearly stated: "I'll be 90 days clean come 02/09/22 and I'll arrange an appointment at that time to get a CMHT referral." (our emphasis). 4
ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patient is an addict. The "discussion" was between the Deceased and his liver specialist and was followed up in writing, by letter dated 18 August 2022 marked as copied to the Deceased. See Response at 2. i. above which is reiterated. The Deceased had capacity. At this time the Practice were already using AccuRx to provide written safety netting information to patients. However, in this instance, the conversation was between the hepatology consultant and the patient, with the Practice/GP never involved in the mental health/CMHT discussion. The Practice will continue to use AccuRx to provide written safety netting information to patients. The Practice Partners have discussed collectively their position is not to routinely send letters to remind patients to request a referral.
iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period ofsobriety unless the patient "opted out" or where following an automatic referral it is left to the Mental Health team to seek the co operation ofthe patient. A system of referring patients with addiction automatically to mental health services after a specified period of abstinence without GP review/discussion/assessment would not be appropriate or workable. There is always a risk of relapse at any point during the 90 day period making review in advance of referral necessary. Further, a period of abstinence may also have changed the patient's mental health condition, meaning a referral is no longer necessary/appropriate. If the Deceased had been referred to CMHT at that time (following a GP review) and as he was not psychotic/higher risk, then any such referral would have been made on a routine (not urgent) basis. However, it is also the Practice's experience that many such patients are signposted back to drug and alcohol services for counselling. The Deceased was already under "We Are With You" and had access to counselling. In the event an automatic system were to be implemented (which the Practice consider inappropriate), mental health services would be inundated by referrals, where capacity is already limited and lots of drugs and alcohol referrals are already being rejected in the Practice's experience. 5
iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities ofthe doctor and patient. " The plan for CMHT review was discussed between the Deceased and his hepatologist and (as marked on the letter) the Deceased would have received a copy of the letter sent to the GP practice, following that consultation confirming the plan. The Practice reiterates its responses to 1. i. and ii. and concerns 2. i. and ii. above. STEPS TAKEN BY THE PRACTICE
8. On notification of the Deceased' s death and as part of their "death audit" ( concerning an unexpected death), the Practice conducted a "death analysis"/SEA on 25 January 2023. This was prior to being notified of the cause of death by the Coroner. This was led by Dr Rasool.
9. Following the Inquest, and receipt of the Regulation 28 Report, the Practice has also undertaken further extensive steps:
9.1. The Partners have discussed the circumstances of the death, H.M. Assistant Coroner's concerns and considered whether there needs to be any change to practise, at Partners' meetings on 7 and 21 August 2023.
9.2. The Practice have sought and obtained copies of the CMHT referral pathways from the Integrated Service Manager for Bournemouth East CMHT, the "Pan Dorset Guidance/Process" and "Integrated Community Mental Health Team Procedures" copies of which are attached. These had not previously been provided to the Practice. These were requested on 9 August 2023 and obtained on 10 August 2023. The CMHT's referral criteria does not specify a requirement for 90 days' abstinence.
9.3. Under the Pan Dorset Guidance/Process the Deceased fell into "Quadrant A":
• Individuals within this quadrant would be experiencing significant mental health problems and high drug and/or alcohol use (of any drug and/or alcohol).
• Individuals should be typically receiving care from both statutory mental health services and substance misuse services, where treatment such as opiate substitute prescribing, or alcohol detox would be in place.
• Joint responsibility for coordination would be required for this group with commitment to joint assessment, care planning and treatment
• If the individual only engages with either the substance misuse service OR the mental health service then either service should request advice, guidance and support from the other as necessary.
9.4. Liaised with the Care Quality Commission (CQC) in response to initial contact from them. The CQC representative planned to raise with the Integrated Care Board ("ICB") Quality Lead. 6
9.5. Raised the wider system approach with the ICB directly, namely the ICB Quality Lead and Patient Safety Specialist for Dorset, having obtained details from contact with the CQC. Emailed for guidance on addressing the wider system and attempted to clarify whether there is a "90 day abstinence rule" for CMHT referrals.
9.6. Following discussion with the ICB communications lead on 3 August 2023, obtained a copy mental health Z card on 17 August 2023, as attached (which the Practice do already have and use but did not have opportunity to give to the Deceased in this case due to lack of mental health contact)
9.7. Contacted and met with ICB Patient Safety Services on 30 August 2023. Established there is a review underway of the service provision for patients with alcohol dependency but that is still at the fact finding stage and the timeframe for completion is realistically not until the middle of
2024.
9.8. By way of follow up meeting on 25 September 2023 (Practice Manager) and
attended a meeting with (Patient Safety at Dorchester Hospital and University Hospitals Dorset) (ICB Transformation Lead),
(Secondary Care Mental Health Service Lead), (ICB Patient Safety Lead) to discuss matters arising and referral criteria to CMHT. The pertinent discussion points of relevance were:
9.8.1 Mental Health Integrated Community Services (MHIC) long term plan was released pre- COVID. It lays out unmet needs for patients with mental health, addiction and wellbeing concerns. A big part of the current plan is around regular multi-disciplinary ("MDT") meetings between these services coordinated by new 'wellbeing coordinators' (to be employed at PCN/Neighbourhood level). GPs will be invited to attend these meetings to improve communication/patients bouncing around services with no-one taking ownership. It is specifically designed so patients can contact the wellbeing coordinators themselves for help as and when needed, rather than GPs needing to refer each time. Poole and Weymouth are currently running pilots for this model, but this is not likely to be up and running locally until May 2024 at the earliest.
9.8.2 GP Practices do now have the addition of a CMHT link worker which everyone agreed was a very valuable communication asset.
9.8.3 The 90 days' sobriety has never been a 'rule'/ referral criteria. It's likely a historic/ misunderstood 'old wives tale'. Discussed the length of the referral criteria document, which it was agreed was unhelpful for clinicians. CMHT stated this was their policy rather than one aimed for referring clinicians to use. All agreed it would be helpful to have a shorter/punchier summary for clinicians to use going forwards. This will be a matter for CMHT to prepare a revised version. 7
9.8.4 In the case of the Deceased, he was under 'We Are With You'. It was confirmed that they could refer into CMHT if they thought it necessary. No data is available on how many referrals 'We Are With You' make, but anecdotally, not many as they have their own Psychiatric nurses.
9.8.5 Plan to prepare a shared learning summary jointly with ICB. ICB are already providing mental health Z cards to acute services/ A&E departments. CMHT are in the process of constructing an SBAR (situation, background, assessment, recommendation) communication tool for acute services detailing criteria for referral to CMHT. 8
1. H.M. Assistant Coroner Middleton for the Coroner Area of Dorset has made a Regulation 28 Report Action to prevent deaths dated 1 August 2023 ("the Regulation 28 Report") concerning the death of Edward England Rhodes ("the Deceased"). This arises from the Inquest of 27 July 2023 ("the Inquest").
2. The Regulation 28 Report is addressed to the Practice Manager at the Beaufort Road Surgery, 21 Beaufort Road, Southboume, Bournemouth, Dorset, BH6 SAJ ("the Practice"), which is a general medical practice. This is the response of the Partners in the Practice to the Regulation 28 Report in accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013 ("the Response"). BACKGROUND
3. , is a GP Partner in the Practice.
4. H.M. Coroner for Dorset's office requested, in a letter addressed to the Practice dated 7 February 2023, "a signed statement into the medical history of the deceased and advise ofany treatment or medication you prescribed within the six months preceding his death." provided H.M. Coroner with a statement addressing the matters in accordance with this request, dated 7 March 2023.
5. Neither the Practice nor , were afforded Interested Person ("IP") status for the Inquest. The Practice and were not therefore legally represented at the Inquest and were not provided with disclosure of the Inquest Bundle. 0
6. gave evidence (virtually) at the Inquest on 27 July 2023. He was the first witness to give evidence and was discharged once his evidence had concluded. He did not hear any of the subsequent evidence and played no further part in the Inquest. There were no other attendees from/for the Practice.
PRACTICE RESPONSE TO REGULATION 28 REPORT
7. The numbering in the Regulation 28 Report is adopted. H.M. Assistant Coroner Middleton's comments/concerns are set out in italics, with the Practice's Response below: "The MATTERS OF CONCERN are as follows
1. During the inquest evidence was heard that:
i. Mr Rhodes wanted to address the underlying causes for his addiction. He wished to be referred to the Mental Health Team for an assessment. He was told by medical professionals that he needed to be 90 days sober. In respect of the first sentence the Deceased had a long-standing history of addiction. He had been a patient at the Practice from 6 February 2020, until his death. He first expressed a desire to his hepatologist (liver specialist), Dr Clare Harris, for referral to the Community Mental Health Team ("CMHT") on 16 August 2022 (having never previously expressed such a wish to the Practice). For the sake of clarity, the GPs at the Practice were not the medical professionals who first told the Deceased the information contained in the second sentence. This came from (an)other medical professional(s). Of note, the Deceased saw his hepatologist (liver specialist), , on 16 August
2022. Following which the Practice received a letter from dated 18 August 2022 and which states (our emphasis): "[the Deceased] is concerned that he may have an underlying mental health disorder that contributes to his relapses and is very keen to be seen by CMHT. However, he is aware that he needs to be completely abstinent of alcohol and recreational drugs for a period of 90 days before this referral can be made." ' letter is also marked as copied to the Deceased.
ii. Mr Rhodes saw his GP and it was confirmed during evidence that a referral would be made by the GP after a period of90 days abstinence. left after giving his evidence and neither he nor the Practice were represented at the Inquest to hear what others may have said in their evidence. does not recall giving evidence to the effect that "a referral would be made by the GP after a period of 90 days abstinence" and nor does his Statement state this. Following his consultation with his hepatologist on 16 August 2022, the relevant chronology is: 2
• The Deceased next contacted the Practice online on 22 August 2022, by e- Consult requesting an extended sick note until 31 October 2022. The Deceased stated (our emphasis): " .. . I'll be 90 days clean come 02/09/22 and I'll arrange an appointment at that time to get a CMHT referral."
• Thee-Consult was triaged and a new eMED3 (sick note) issued by on 23 August 2022.
• The Deceased attended a face to face consultation with on 14 September 2022 with an unrelated complaint. That was an urgent, same day appointment for tonsillitis. confirmed in his evidence that the Deceased did not mention nor request anything about his mental health at this consultation, he did not discuss the CMHT referral or "requirement" for 90 days abstinence during this consultation. gave evidence that the Deceased was acutely unwell from tonsilitis. The attendance was entirely unrelated and addressed only the Deceased's acute presentation with tonsillitis.
• The Deceased's next and final contact with the Practice was on 28 October 2022, again by e-Consult, seeking a sick note extension until 24 December 2022. The e-Consult was triaged and a new eMED3 (sick note) issued by the same day. The Practice were aware from ' letter and the Deceased's e-Consult message of 22 August 2022 that he was trying to achieve 90 days' abstinence. As his eConsult message of that date (set out above) clearly states, the Deceased also knew he needed to initiate the contact with the Practice for a consultation for a mental health review, in order to receive a CMHT referral if appropriate, and he planned to do this.
iii. Mr Rhodes' GP explained that in order to make a referral Mr Rhodes had to make a specific appointment to discuss the Mental Health referral. The GP said that Mr Rhodes was aware ofthis. This is correct. The response at ii above is reiterated.
iv. Mr Rhodes saw his GP on 14/10/22 (at that time he had been sober in excess of90 days) for a medical condition. On that occasion there was no discussion about the Mental Health referral. This is correct. As explained in the Response at ii above, the appointment was in respect of an unrelated, urgent presentation with tonsilitis. There was no discussion of his sobriety or CMHT referral. 3
v. Mr Rhodes 'family (who were close to him and had discussions with him) gave evidence to say that his understanding was that following the 90 day period of sobriety there would be an automatic referral by his GP to the Mental Health Services. This reflects the family's evidence of their understanding of the Deceased's belief. Response ii above is reiterated.
vi. The report from the addiction support agency details entries whereby during discussion with his Recovery Worker Mr Rhodes provides a detailed chronology of his period of abstinence and the fact he was waiting to hear from the Mental Health Services for an assessment appointment. This reflects the evidence heard.
vii. Mr Rhodes' partner gave evidence that at the time he started to relapse he was still waiting for a date from the Mental Health Services and that he was expressing disillusionment with the Mental Health Services. This reflects the evidence heard.
2. I have concerns with regard to the following:
i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral. The Practice do not accept that there was either a breakdown in communication nor miscommunication between the Practice/GPs and the Deceased. The discussion concerning the CMHT referral was between the Deceased and his hepatologist, not the GPs. The hepatologist's letter to the Practice (18 August 2022) is marked as copied to the Deceased so he would/should have had the written communication, see response to 1. ii above for details. It is evident from the Deceased's e-Consult email to the Practice on 22 August 2022, that the Deceased was aware that he himself needed to make an appointment with the Practice to discuss his mental health in order to get a CMHT referral. As the Deceased clearly stated: "I'll be 90 days clean come 02/09/22 and I'll arrange an appointment at that time to get a CMHT referral." (our emphasis). 4
ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patient is an addict. The "discussion" was between the Deceased and his liver specialist and was followed up in writing, by letter dated 18 August 2022 marked as copied to the Deceased. See Response at 2. i. above which is reiterated. The Deceased had capacity. At this time the Practice were already using AccuRx to provide written safety netting information to patients. However, in this instance, the conversation was between the hepatology consultant and the patient, with the Practice/GP never involved in the mental health/CMHT discussion. The Practice will continue to use AccuRx to provide written safety netting information to patients. The Practice Partners have discussed collectively their position is not to routinely send letters to remind patients to request a referral.
iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period ofsobriety unless the patient "opted out" or where following an automatic referral it is left to the Mental Health team to seek the co operation ofthe patient. A system of referring patients with addiction automatically to mental health services after a specified period of abstinence without GP review/discussion/assessment would not be appropriate or workable. There is always a risk of relapse at any point during the 90 day period making review in advance of referral necessary. Further, a period of abstinence may also have changed the patient's mental health condition, meaning a referral is no longer necessary/appropriate. If the Deceased had been referred to CMHT at that time (following a GP review) and as he was not psychotic/higher risk, then any such referral would have been made on a routine (not urgent) basis. However, it is also the Practice's experience that many such patients are signposted back to drug and alcohol services for counselling. The Deceased was already under "We Are With You" and had access to counselling. In the event an automatic system were to be implemented (which the Practice consider inappropriate), mental health services would be inundated by referrals, where capacity is already limited and lots of drugs and alcohol referrals are already being rejected in the Practice's experience. 5
iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities ofthe doctor and patient. " The plan for CMHT review was discussed between the Deceased and his hepatologist and (as marked on the letter) the Deceased would have received a copy of the letter sent to the GP practice, following that consultation confirming the plan. The Practice reiterates its responses to 1. i. and ii. and concerns 2. i. and ii. above. STEPS TAKEN BY THE PRACTICE
8. On notification of the Deceased' s death and as part of their "death audit" ( concerning an unexpected death), the Practice conducted a "death analysis"/SEA on 25 January 2023. This was prior to being notified of the cause of death by the Coroner. This was led by Dr Rasool.
9. Following the Inquest, and receipt of the Regulation 28 Report, the Practice has also undertaken further extensive steps:
9.1. The Partners have discussed the circumstances of the death, H.M. Assistant Coroner's concerns and considered whether there needs to be any change to practise, at Partners' meetings on 7 and 21 August 2023.
9.2. The Practice have sought and obtained copies of the CMHT referral pathways from the Integrated Service Manager for Bournemouth East CMHT, the "Pan Dorset Guidance/Process" and "Integrated Community Mental Health Team Procedures" copies of which are attached. These had not previously been provided to the Practice. These were requested on 9 August 2023 and obtained on 10 August 2023. The CMHT's referral criteria does not specify a requirement for 90 days' abstinence.
9.3. Under the Pan Dorset Guidance/Process the Deceased fell into "Quadrant A":
• Individuals within this quadrant would be experiencing significant mental health problems and high drug and/or alcohol use (of any drug and/or alcohol).
• Individuals should be typically receiving care from both statutory mental health services and substance misuse services, where treatment such as opiate substitute prescribing, or alcohol detox would be in place.
• Joint responsibility for coordination would be required for this group with commitment to joint assessment, care planning and treatment
• If the individual only engages with either the substance misuse service OR the mental health service then either service should request advice, guidance and support from the other as necessary.
9.4. Liaised with the Care Quality Commission (CQC) in response to initial contact from them. The CQC representative planned to raise with the Integrated Care Board ("ICB") Quality Lead. 6
9.5. Raised the wider system approach with the ICB directly, namely the ICB Quality Lead and Patient Safety Specialist for Dorset, having obtained details from contact with the CQC. Emailed for guidance on addressing the wider system and attempted to clarify whether there is a "90 day abstinence rule" for CMHT referrals.
9.6. Following discussion with the ICB communications lead on 3 August 2023, obtained a copy mental health Z card on 17 August 2023, as attached (which the Practice do already have and use but did not have opportunity to give to the Deceased in this case due to lack of mental health contact)
9.7. Contacted and met with ICB Patient Safety Services on 30 August 2023. Established there is a review underway of the service provision for patients with alcohol dependency but that is still at the fact finding stage and the timeframe for completion is realistically not until the middle of
2024.
9.8. By way of follow up meeting on 25 September 2023 (Practice Manager) and
attended a meeting with (Patient Safety at Dorchester Hospital and University Hospitals Dorset) (ICB Transformation Lead),
(Secondary Care Mental Health Service Lead), (ICB Patient Safety Lead) to discuss matters arising and referral criteria to CMHT. The pertinent discussion points of relevance were:
9.8.1 Mental Health Integrated Community Services (MHIC) long term plan was released pre- COVID. It lays out unmet needs for patients with mental health, addiction and wellbeing concerns. A big part of the current plan is around regular multi-disciplinary ("MDT") meetings between these services coordinated by new 'wellbeing coordinators' (to be employed at PCN/Neighbourhood level). GPs will be invited to attend these meetings to improve communication/patients bouncing around services with no-one taking ownership. It is specifically designed so patients can contact the wellbeing coordinators themselves for help as and when needed, rather than GPs needing to refer each time. Poole and Weymouth are currently running pilots for this model, but this is not likely to be up and running locally until May 2024 at the earliest.
9.8.2 GP Practices do now have the addition of a CMHT link worker which everyone agreed was a very valuable communication asset.
9.8.3 The 90 days' sobriety has never been a 'rule'/ referral criteria. It's likely a historic/ misunderstood 'old wives tale'. Discussed the length of the referral criteria document, which it was agreed was unhelpful for clinicians. CMHT stated this was their policy rather than one aimed for referring clinicians to use. All agreed it would be helpful to have a shorter/punchier summary for clinicians to use going forwards. This will be a matter for CMHT to prepare a revised version. 7
9.8.4 In the case of the Deceased, he was under 'We Are With You'. It was confirmed that they could refer into CMHT if they thought it necessary. No data is available on how many referrals 'We Are With You' make, but anecdotally, not many as they have their own Psychiatric nurses.
9.8.5 Plan to prepare a shared learning summary jointly with ICB. ICB are already providing mental health Z cards to acute services/ A&E departments. CMHT are in the process of constructing an SBAR (situation, background, assessment, recommendation) communication tool for acute services detailing criteria for referral to CMHT. 8
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- Beaufort Road Surgery
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26 Sep 2023
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 23rd November 2022, an investigation was commenced into the death of Edward England Rhodes, born on the 9th July 1989.
The investigation concluded at the end of the Inquest on the 27th July 2023.
The Medical Cause of Death was:
1a Methadone Toxicity
The conclusion of the Inquest recorded.
Drug Related Death
The investigation concluded at the end of the Inquest on the 27th July 2023.
The Medical Cause of Death was:
1a Methadone Toxicity
The conclusion of the Inquest recorded.
Drug Related Death
Circumstances of the Death
Mr Rhodes had a long history of alcohol misuse. He had been admitted to hospital numerous times for alcohol related issues. He lived in supported housing where he was tested regularly for substance misuse. In June 2022 he chose to abstain from alcohol and sought the help and support of agencies to prevent relapse. On 14/7/22 he stated he was over 1 month sober; on 18/8/22 he was 76 days sober; on 2/9/22 he stated he was 90 days sober; and by 16/11/22 he had been abstinent for 4-5 months. At the beginning of November 2022, he relapsed. On 17/11/22 he was found on his partner’s bedroom floor in an unresponsive state and was pronounced dead at the scene. Toxicology revealed the presence of methadone, which was at a level consistent with severe, possibly fatal toxicity for an individual who is naïve to or occasional user of methadone. Mr Rhodes was not on a methadone prescription at the time of his death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.