Jonathan Cole
PFD Report
All Responded
Ref: 2023-0186
All 2 responses received
· Deadline: 31 Jul 2023
Coroner's Concerns (AI summary)
There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access to appropriate mental health diagnosis and treatment, compounded by ongoing recruitment difficulties.
View full coroner's concerns
Ministry of Defence
1. I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel. This concern extends to ensuring a soldier receives access to appropriate treatment including diagnosis.
Diagnosis is also important as under the Armed Forces Compensation Scheme, mental disorders must be diagnosed by a relevant accredited medical specialist, namely, a medical practitioner whose name is included in the specialist register kept and published by the General Medical Council as required by section 34D of the Medical Act 1983.
At the time Jonny Cole was accessing the DCMH Lisburn, gave evidence that there was just one psychiatrist for the whole of Northern Ireland who also had duties in the DCMH Kinloss, Scotland and no psychologist. 2 Rifles was based in Northern Ireland and at this time issues relative to Operation Herrick 10 and traumatic combat experience were being identified.
told me relative to the impact of Operation Herrick 10, “Well all I can say is that we knew that we had a problem with post traumatic stress disorder and there were several suicides in Northern Ireland before I arrived. I can’t comment on that too far because there was a board of inquiry and the regiment was moved from the isolated position of Ballykinler to Lisburn because of that. In order to make them less vulnerable,”
Following the evidence given by , I queried the Service expectations for the number of psychiatrists covering Northern Ireland and Scotland in 2010-2013 and now, and was provided with the following response from Defence Medical Services.
“NI is now covered by DCMH . The staffing of mental health posts is however now lower that that at the time the Coroner is concerned with. This is partly due to reducing military population in NI which would not justify a full-time consultant and partly due to significant difficulties in staffing mental health posts. Recruiting more mental health clinical staff is something that the DMS is working hard to do; however, the pool of mental health workers for both the DMS and NHS to draw from is finite.
Additionally, the DPHC Standard Operating Procedure on management of referrals makes some reference to this. Though it does not specify a manning ratio, it does give guidance on waiting list management (para 13). In essence it states an Officer Rank 7 or Civil Service Band 6 has day to day responsibility for monitoring waiting lists and has direct access to the clinical lead, they are also responsible for all review arrangements and Multi-Disciplinary Team actions which are in place. It would follow from this if waiting lists are becoming unmanageable the named individual would be able to escalate the problem”.
Chief of Staff at Defence Medical Services Headquarters, gave evidence when asked about the current position as to whether there was shortage of consultant psychiatrists and psychologists within the DCMHs, that, “we certainly have a shortage of mental health clinical staff at the moment. There are a lot of initiatives in place to try and continue to recruit those both military and civilian and we are working very hard at producing a more resilient and enduring so that we can actually build a career structure for our mental health practices going forward, something we have lacked in defence up until now.”
This concern also extends to the knock-on effect that this apparent shortage of psychiatrists and psychologists has upon later claims for compensation by veterans as mental disorders must be diagnosed by a relevant accredited medical specialist, namely, a medical practitioner whose name is included in the specialist register kept and published by the General Medical Council as required by section 34D of the Medical Act 1983.
2. I have a concern that the Vulnerability Risk Management Process [Suicide Vulnerability Risk Management as was] is Unit led and that DCMH clinicians do not have a greater role in influencing the Army’s vulnerability risk management (VRM) process for suicidal soldiers.
3. I have a concern about:
a. the training and experience of the Medical Advisors at Veterans UK providing advice under the Armed Forces Compensation Scheme.
b. rejection of claims for PTSD under the Armed Forces Compensation Scheme if there is not a formal diagnosis by a consultant psychiatrist or psychologist but evidence of PTSD within medical records from other medical professionals.
was a retired GP who went on to work as a part-time medical advisor at Veterans UK in October 2013 and rejected Jonny’s claim for compensation for PTSD and psychological injury under the armed forces compensation scheme. had no specialist knowledge of psychiatric or mental health issues and had had no specialist training in that area.
In evidence accepted that there was an issue with the advice he gave that resulted in Jonny’s claim for compensation being rejected. In evidence told me: “Q. Can I ask you: The approach that you adopted on Jonny Cole’s case, in respect of his claim to PTSD, would you have applied a similar approach to other files or claims of veterans in respect of PTSD? A. It’s possible, I suppose, but I suppose as you gain experience and understanding of how the scheme is to be applied, then it changes. When I looked at this a week ago, which is when I first saw the documents, I could see straightaway the issue, but obviously I didn’t see that in December 2013.
Q. So, then, can I ask you: Obviously, when you reviewed the file as part of your preparation to give evidence, and to be fair to you, you had not had that opportunity when you provided your statement, you say you saw straightaway what the issue was. Can you tell us what it was that you saw when you reviewed the file, and what that issue is? A. That there was a consultant diagnosis1.
Q. Would there ever have been a scenario where you had rejected a claim, as part of the advice that you had given to the case workers, where a veteran would come back and say… Be raising issues again about PTSD, would it come back to you to review or would it go to a different medical adviser? A. It could be either, and in fact if a review was requested or an appeal requested, I think it had to be a different case worker, but I don’t think it necessarily had to be a different medical adviser.
Q. Just so then I am clear about you reviewed the file with obviously then the knowledge… Admittedly you do not work for Veterans UK anymore, but you had had the number of years then working and giving advice. But when you saw straightaway what the issue was, and there was a consultant diagnosis, if you had reviewed Jonny Cole’s case nearer to the end of your time at Veterans UK, what would your advice have been in respect of Jonny Cole’s claim, to the case workers? A. Well, it would have been a different approach, because I would… Once you have accepted that there is a diagnosis, then the next stage is what’s the cause of that, and is that predominantly caused by factors of service? And then, if the answer to that is yes, on the balance of probabilities it is caused by factors of service, then I would have recommended an award.
Q. Then, in terms of what you have effectively told us, that if you had reviewed this case later down your experience with Veterans UK, Jonny certainly would have got over the hurdle of a consultant diagnosis–– A. Yes.
Q.
––but again, having reviewed the documentation, and obviously you were the individual that was asked to provide advice as to
1 Adjustment Disorder. also gave evidence that he would have applied the diagmosis of PTSD in remission. causation, to provide advice as to whether or not on the balance of probability it is linked to factors relating to service… Have you gone on to consider that aspect also? A. Not particularly no, but I would have thought there’s enough there to say yes it was.”
indicated that the “narrow look” he undertook in respect of Jonny’s claim for compensation was due to, “Certainly not lack of time. I think it would be fair to say possibly lack of experience, and lack of training. And I think the emphasis I think was quite strong on that principle, even within the table tariff for the AFCS, on the section 3 I think it is, which is for psychological things, I think it does state it there, that a diagnosis can only be accepted by accredited consultant psychiatrist, so I suppose that in a sense emphasises it, and perhaps that’s why it was so prominent in my thinking.”
gave expert evidence to me about the impact of the denial of compensation by Veterans UK for psychological injury and decisions where there is a denial of payments to which a veteran is entitled which, invalidates psychological injury, can cause hostility and being aggrieved and lead to self-destructive behaviour by the veteran.
Jonny Cole himself raised by email to Veterans UK in June 2018, and shortly before his death in August 2018, the ongoing issues he was having with his PTSD that was getting worse and the impact it was having on his mental health, which had led to hospital admission due to overdose, and included a letter that identified that Jonny had reported thinking of suicide on a daily basis.
Jonny Cole did not receive a response to this email before his death but when this response was provided by letter dates 20th August 2018 it stated;
“We cannot take any further action on your claim at the moment. This is because the scheme rules state when considering a claim for a mental disorder, we require a diagnosis made by a clinical psychologist or psychiatrist at consultant grade. We are unable to accept a diagnosis made by a GP or community psychiatric nurse.
Evidence we have considered so far: We have looked at the evidence we already have but it does not include confirmation of a formal diagnosis.
What happens next: In order for us to be able to fully consider your claim, please could you provide us with evidence of a diagnosis from a consultant psychologist or psychiatrist. We are unable to take any further action until we hear from you. If we do not receive a response from you within 3 months of our request, your claim will be closed.” suggested that thought needed to be given to having a Panel that is more representative of all stake holders not just the MOD and for more credibility to be given to civilian diagnosis and evidence and for there to be someone independent to review the cases.
Nottinghamshire Healthcare NHS Foundation Trust [The Trust]
4. I have a concern that the Trust is doing too little to identify and address the risk of suicide for Veterans.
A 2021 Nottinghamshire Suicide Prevention Action Plan to which the Trust was a partner identified for Veterans the need to, “undertake evidence review on the needs of veterans in relation to mental health and suicide, to inform future developments. Promote and raise awareness of the Op Courage MH Pathway and Armed Forces Health eLearning (commissioned by NHSE/Improvement Armed Forces Health). Ensure an ongoing dialogue with NHSE/Improvement around provision of mental health, suicide prevention and postvention. bereavement support to veterans and engage in any NHSE Midlands masterclass with Integrated Care Boards (ICBs) - date to be agreed. Identify veterans within the local Suicide Cluster Response Plan Guidance in the first annual refresh Review learning from the NHSE/Improvement review/investigation of Serious Incidents.”
Despite this, the Trust’s Suicide Prevention Strategy and Suicide Prevention Annual Plan 2020-2023 provided to me and due to be reviewed this year does not specifically touch upon Veterans. I am told that there is a commitment to ensure this is a key feature of the review already commencing within the organisation.
5. I have a concern that there is: a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners; b) a lack of understanding as to services available for Veterans; c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services; d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
1. I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel. This concern extends to ensuring a soldier receives access to appropriate treatment including diagnosis.
Diagnosis is also important as under the Armed Forces Compensation Scheme, mental disorders must be diagnosed by a relevant accredited medical specialist, namely, a medical practitioner whose name is included in the specialist register kept and published by the General Medical Council as required by section 34D of the Medical Act 1983.
At the time Jonny Cole was accessing the DCMH Lisburn, gave evidence that there was just one psychiatrist for the whole of Northern Ireland who also had duties in the DCMH Kinloss, Scotland and no psychologist. 2 Rifles was based in Northern Ireland and at this time issues relative to Operation Herrick 10 and traumatic combat experience were being identified.
told me relative to the impact of Operation Herrick 10, “Well all I can say is that we knew that we had a problem with post traumatic stress disorder and there were several suicides in Northern Ireland before I arrived. I can’t comment on that too far because there was a board of inquiry and the regiment was moved from the isolated position of Ballykinler to Lisburn because of that. In order to make them less vulnerable,”
Following the evidence given by , I queried the Service expectations for the number of psychiatrists covering Northern Ireland and Scotland in 2010-2013 and now, and was provided with the following response from Defence Medical Services.
“NI is now covered by DCMH . The staffing of mental health posts is however now lower that that at the time the Coroner is concerned with. This is partly due to reducing military population in NI which would not justify a full-time consultant and partly due to significant difficulties in staffing mental health posts. Recruiting more mental health clinical staff is something that the DMS is working hard to do; however, the pool of mental health workers for both the DMS and NHS to draw from is finite.
Additionally, the DPHC Standard Operating Procedure on management of referrals makes some reference to this. Though it does not specify a manning ratio, it does give guidance on waiting list management (para 13). In essence it states an Officer Rank 7 or Civil Service Band 6 has day to day responsibility for monitoring waiting lists and has direct access to the clinical lead, they are also responsible for all review arrangements and Multi-Disciplinary Team actions which are in place. It would follow from this if waiting lists are becoming unmanageable the named individual would be able to escalate the problem”.
Chief of Staff at Defence Medical Services Headquarters, gave evidence when asked about the current position as to whether there was shortage of consultant psychiatrists and psychologists within the DCMHs, that, “we certainly have a shortage of mental health clinical staff at the moment. There are a lot of initiatives in place to try and continue to recruit those both military and civilian and we are working very hard at producing a more resilient and enduring so that we can actually build a career structure for our mental health practices going forward, something we have lacked in defence up until now.”
This concern also extends to the knock-on effect that this apparent shortage of psychiatrists and psychologists has upon later claims for compensation by veterans as mental disorders must be diagnosed by a relevant accredited medical specialist, namely, a medical practitioner whose name is included in the specialist register kept and published by the General Medical Council as required by section 34D of the Medical Act 1983.
2. I have a concern that the Vulnerability Risk Management Process [Suicide Vulnerability Risk Management as was] is Unit led and that DCMH clinicians do not have a greater role in influencing the Army’s vulnerability risk management (VRM) process for suicidal soldiers.
3. I have a concern about:
a. the training and experience of the Medical Advisors at Veterans UK providing advice under the Armed Forces Compensation Scheme.
b. rejection of claims for PTSD under the Armed Forces Compensation Scheme if there is not a formal diagnosis by a consultant psychiatrist or psychologist but evidence of PTSD within medical records from other medical professionals.
was a retired GP who went on to work as a part-time medical advisor at Veterans UK in October 2013 and rejected Jonny’s claim for compensation for PTSD and psychological injury under the armed forces compensation scheme. had no specialist knowledge of psychiatric or mental health issues and had had no specialist training in that area.
In evidence accepted that there was an issue with the advice he gave that resulted in Jonny’s claim for compensation being rejected. In evidence told me: “Q. Can I ask you: The approach that you adopted on Jonny Cole’s case, in respect of his claim to PTSD, would you have applied a similar approach to other files or claims of veterans in respect of PTSD? A. It’s possible, I suppose, but I suppose as you gain experience and understanding of how the scheme is to be applied, then it changes. When I looked at this a week ago, which is when I first saw the documents, I could see straightaway the issue, but obviously I didn’t see that in December 2013.
Q. So, then, can I ask you: Obviously, when you reviewed the file as part of your preparation to give evidence, and to be fair to you, you had not had that opportunity when you provided your statement, you say you saw straightaway what the issue was. Can you tell us what it was that you saw when you reviewed the file, and what that issue is? A. That there was a consultant diagnosis1.
Q. Would there ever have been a scenario where you had rejected a claim, as part of the advice that you had given to the case workers, where a veteran would come back and say… Be raising issues again about PTSD, would it come back to you to review or would it go to a different medical adviser? A. It could be either, and in fact if a review was requested or an appeal requested, I think it had to be a different case worker, but I don’t think it necessarily had to be a different medical adviser.
Q. Just so then I am clear about you reviewed the file with obviously then the knowledge… Admittedly you do not work for Veterans UK anymore, but you had had the number of years then working and giving advice. But when you saw straightaway what the issue was, and there was a consultant diagnosis, if you had reviewed Jonny Cole’s case nearer to the end of your time at Veterans UK, what would your advice have been in respect of Jonny Cole’s claim, to the case workers? A. Well, it would have been a different approach, because I would… Once you have accepted that there is a diagnosis, then the next stage is what’s the cause of that, and is that predominantly caused by factors of service? And then, if the answer to that is yes, on the balance of probabilities it is caused by factors of service, then I would have recommended an award.
Q. Then, in terms of what you have effectively told us, that if you had reviewed this case later down your experience with Veterans UK, Jonny certainly would have got over the hurdle of a consultant diagnosis–– A. Yes.
Q.
––but again, having reviewed the documentation, and obviously you were the individual that was asked to provide advice as to
1 Adjustment Disorder. also gave evidence that he would have applied the diagmosis of PTSD in remission. causation, to provide advice as to whether or not on the balance of probability it is linked to factors relating to service… Have you gone on to consider that aspect also? A. Not particularly no, but I would have thought there’s enough there to say yes it was.”
indicated that the “narrow look” he undertook in respect of Jonny’s claim for compensation was due to, “Certainly not lack of time. I think it would be fair to say possibly lack of experience, and lack of training. And I think the emphasis I think was quite strong on that principle, even within the table tariff for the AFCS, on the section 3 I think it is, which is for psychological things, I think it does state it there, that a diagnosis can only be accepted by accredited consultant psychiatrist, so I suppose that in a sense emphasises it, and perhaps that’s why it was so prominent in my thinking.”
gave expert evidence to me about the impact of the denial of compensation by Veterans UK for psychological injury and decisions where there is a denial of payments to which a veteran is entitled which, invalidates psychological injury, can cause hostility and being aggrieved and lead to self-destructive behaviour by the veteran.
Jonny Cole himself raised by email to Veterans UK in June 2018, and shortly before his death in August 2018, the ongoing issues he was having with his PTSD that was getting worse and the impact it was having on his mental health, which had led to hospital admission due to overdose, and included a letter that identified that Jonny had reported thinking of suicide on a daily basis.
Jonny Cole did not receive a response to this email before his death but when this response was provided by letter dates 20th August 2018 it stated;
“We cannot take any further action on your claim at the moment. This is because the scheme rules state when considering a claim for a mental disorder, we require a diagnosis made by a clinical psychologist or psychiatrist at consultant grade. We are unable to accept a diagnosis made by a GP or community psychiatric nurse.
Evidence we have considered so far: We have looked at the evidence we already have but it does not include confirmation of a formal diagnosis.
What happens next: In order for us to be able to fully consider your claim, please could you provide us with evidence of a diagnosis from a consultant psychologist or psychiatrist. We are unable to take any further action until we hear from you. If we do not receive a response from you within 3 months of our request, your claim will be closed.” suggested that thought needed to be given to having a Panel that is more representative of all stake holders not just the MOD and for more credibility to be given to civilian diagnosis and evidence and for there to be someone independent to review the cases.
Nottinghamshire Healthcare NHS Foundation Trust [The Trust]
4. I have a concern that the Trust is doing too little to identify and address the risk of suicide for Veterans.
A 2021 Nottinghamshire Suicide Prevention Action Plan to which the Trust was a partner identified for Veterans the need to, “undertake evidence review on the needs of veterans in relation to mental health and suicide, to inform future developments. Promote and raise awareness of the Op Courage MH Pathway and Armed Forces Health eLearning (commissioned by NHSE/Improvement Armed Forces Health). Ensure an ongoing dialogue with NHSE/Improvement around provision of mental health, suicide prevention and postvention. bereavement support to veterans and engage in any NHSE Midlands masterclass with Integrated Care Boards (ICBs) - date to be agreed. Identify veterans within the local Suicide Cluster Response Plan Guidance in the first annual refresh Review learning from the NHSE/Improvement review/investigation of Serious Incidents.”
Despite this, the Trust’s Suicide Prevention Strategy and Suicide Prevention Annual Plan 2020-2023 provided to me and due to be reviewed this year does not specifically touch upon Veterans. I am told that there is a commitment to ensure this is a key feature of the review already commencing within the organisation.
5. I have a concern that there is: a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners; b) a lack of understanding as to services available for Veterans; c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services; d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
Responses
Noted
The Ministry of Defence outlines existing strategies and policies related to mental health support for military personnel, transition to civilian life, and assistance to veterans and describes reviews of the Armed Forces Compensation Scheme but does not describe specific actions taken or planned in direct response to the concerns. (AI summary)
The Ministry of Defence outlines existing strategies and policies related to mental health support for military personnel, transition to civilian life, and assistance to veterans and describes reviews of the Armed Forces Compensation Scheme but does not describe specific actions taken or planned in direct response to the concerns. (AI summary)
View full response
Dear Miss Cartwright KC, Thank you for your Regulation 28: Report to Prevent Future Deaths dated 05 June 2023 which detailed concerns identified during the inquest into the very sad death of Army veteran Mr Jonathan ‘Jonny’ Cole. I am grateful to you for your very thorough investigation. The inquest was informed of the significant changes which have taken place over the last decade in the areas of mental health support for military personnel, transition to civilian life and assistance to veterans. I would like to focus briefly on more recent developments in each of these three areas which address the important issues you have raised. Last year saw the publication of the ‘Defence People Health and Wellbeing Strategy 2022-2027’1 with the objective to create, promote and maintain the conditions for Defence People to live healthy lifestyles in healthy environments, reducing injury, illness and suicide as far as possible. Aligned to this effort, the first ever Armed Forces Suicide Prevention Strategy and Action Plan was published in April this year2, detailing the strategic framework within which Defence will take further action to reduce suicide and better support those affected by it. In October 2021 the mandatory Annual Mental Fitness Brief was released, adding to the ‘through life’ mental resilience and stress management training available to personnel. The brief covers the themes of mental health, wellbeing and resilience and details where personnel can seek appropriate help. In 2019 we implemented a holistic transition policy, and this has recently been 1 https://www.gov.uk/government/publications/defence-people-health-and-wellbeing-strategy-2022- to-2027 2 https://www.gov.uk/government/publications/armed-forces-suicide-prevention-strategy-and-action- plan
updated3. The policy introduced a streamlined referral process to assist service personnel leaving the military, and their immediate families, in accessing the support required. The Office for Veterans’ Affairs (OVA) works across government and with private sector organisations, charities and other public sector organisations to support and deliver services to veterans. Its ‘Veterans' Strategy Action Plan’4 sets out commitments the UK Government will deliver to support the objective of making the UK the best place in the world to be a veteran. The OVA has also worked closely with the Department of Health & Social Care and NHS England on the development and promotion of Op Courage, which was launched by the latter in 2021 to provide a broad range of specialist mental health and wellbeing care and support for service leavers, reservists, veterans and their families. This year the MOD and OVA jointly commissioned an Independent Review of UK Government welfare services for veterans5. The review investigated the role, scope and breadth of UK Government welfare provision for veterans, including by the MOD under the Veterans UK banner. The report, published earlier this month, has identified several recommendations to improve welfare provision for veterans across a variety of channels. The recommendations are being closely considered and a formal response is to be published later this year. I have provided below further details in response to the Matters of Concern raised in your report. I hope that this response will illustrate the determination held across Defence to provide the very best support to our people whilst in service and as they transition into civilian life. Our thoughts remain with Mr Cole’s family and friends.
updated3. The policy introduced a streamlined referral process to assist service personnel leaving the military, and their immediate families, in accessing the support required. The Office for Veterans’ Affairs (OVA) works across government and with private sector organisations, charities and other public sector organisations to support and deliver services to veterans. Its ‘Veterans' Strategy Action Plan’4 sets out commitments the UK Government will deliver to support the objective of making the UK the best place in the world to be a veteran. The OVA has also worked closely with the Department of Health & Social Care and NHS England on the development and promotion of Op Courage, which was launched by the latter in 2021 to provide a broad range of specialist mental health and wellbeing care and support for service leavers, reservists, veterans and their families. This year the MOD and OVA jointly commissioned an Independent Review of UK Government welfare services for veterans5. The review investigated the role, scope and breadth of UK Government welfare provision for veterans, including by the MOD under the Veterans UK banner. The report, published earlier this month, has identified several recommendations to improve welfare provision for veterans across a variety of channels. The recommendations are being closely considered and a formal response is to be published later this year. I have provided below further details in response to the Matters of Concern raised in your report. I hope that this response will illustrate the determination held across Defence to provide the very best support to our people whilst in service and as they transition into civilian life. Our thoughts remain with Mr Cole’s family and friends.
Action Taken
The Trust has developed guidance for investigators to consider neurodiversity and reasonable adjustments. They will also proactively review completed investigations and upcoming inquests to identify further learning, ensure family engagement, and summarize key themes to support improvement work. (AI summary)
The Trust has developed guidance for investigators to consider neurodiversity and reasonable adjustments. They will also proactively review completed investigations and upcoming inquests to identify further learning, ensure family engagement, and summarize key themes to support improvement work. (AI summary)
View full response
Dear Ms Cartwright,
Please find below the organisational response to the recently received Preventing Future Deaths Report, following the sad death of Mr Cole.
The Matters of Concern raised within the report that relate to Nottinghamshire Healthcare NHS Foundation Trust (thereafter referred to as the Trust):
Concern that the Trust is doing too little to identify and address the risk of suicide for Veterans
Nottinghamshire Healthcare Trust is committed to working collaboratively with patients and staff to prevent suicide and reduce harm. This includes how we work with patients to meet their needs and also equip our workforce to have the right knowledge and skill to respond effectively to suicidality and promote safety. As such, we have a Trustwide Lead for Suicide Prevention, Rachel Lees. This role is a Trustwide role which is responsible for developing and implementing Nottinghamshire Healthcare’s suicide prevention strategy, and working with other partners across the wider system. This role works strategically and clinically to reduce harm and promote safety in relation to suicidality, particularly focusing on training delivery, clinical practice and sharing of learning and key messages. This role provides expert professional advice, guidance and support, working closely with colleagues at all levels of the organisation to develop and improve practice.
Through triangulation of our mortality surveillance data within Nottinghamshire Healthcare Trust, we recognise that the Veteran group do present with factors that impact on their ability to access and Private and Confidential
Ms S Cartwright HM Assistant Coroner for Derby and Derbyshire Saint Katherines House Saint Mary’s Wharf Mansfield Road Derby DE1 3TQ
14 August 2023
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
receive support. Subsequently, they can present with an increased risk of harm. We are committed as an organisation to supporting this patient group and plan to do the following –
1. The three yearly review of the Suicide Strategy is underway and will include a focus on staff awareness of factors which may be affecting different sub-groups of patients and clinical considerations and implications for practice. Specifically, this will reflect the enhanced risk for the veteran patient group from what we have learnt in the Trust and nationally. Our Trust essential training for Suicide Awareness and response will also reflect this.
2. The Trust holds an annual Suicide Prevention conference where this learning will be reflected. Our colleagues in OpCourage and Trust Armed Forces Community Network will also be in attendance and hosting an information stall.
3. The topic for July’s Trustwide Suicide Prevention Champions Network meeting was Veterans and Suicide Prevention with the Operation Lead for OpCourage Midlands attending as the guest speaker to present and share information about the Armed Forces Covenant and OpCourage with colleagues. This meeting was recorded and is being shared Trustwide through various Communications, including being made available on the Trust’s intranet.
4. Rachel Lees will undertake a thematic review over the next 9 months of patients that are veterans and open to services to understand care and treatment and identify any learning. This will be reported through the Quality Operational Group for learning.
Nottinghamshire Healthcare is also a Gold Member of the Armed Forces Covenant and has recently been re-accredited by Veterans Covenant Healthcare Alliance and are "Veteran Aware." (Appendix
1)
Concern that there is a lack of understanding as to the appropriate services to make referrals to for Veterans by the Trust mental health practitioners.
The Trust has taken action to gain knowledge of appropriate Veteran services which are available, and we are able to make referrals to. As a result of this, we have looked to update our mental health practitioners with regards to this information. All this information has been collated from Nottinghamshire Healthcare culture and staff engagement facilitators, who are part of the Veterans’ Network. Leaflets and posters have been provided and are being distributed throughout the Mental Health Care Group and shared with the wider Trust for review and distribution. As part of the information provided is a card that has a QR code on it, practitioners can scan this code and it takes them to the Veteran information pages on the Nottinghamshire Healthcare Trust intranet site ‘Connect.’
Concern that there is a lack of understanding as to the services available for Veterans.
All inpatient sites now display posters that state that ‘We are Proud to be Veteran Aware’ and include the contact details for the Veterans and families service Champions. Posters are being distributed to all community team bases and will be displayed by the end of August; follow up checks are planned. The Trustwide Lessons Learned Bulletin (Appendix 2) contained information relating to Veterans, and this is shared Trustwide and available on the staff intranet site. Specifically in the Adult Mental Health Care Group the monthly communication the ‘Governance Gazette’ in July (Appendix
3), features an article on Veteran services, this communication is distributed to all teams and is discussed in the team meetings which are attended by all levels of staff. The article also has links to
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
Op Courage and Army and You. The Nottinghamshire Healthcare culture and staff engagement facilitators are presenting to the members of the Adult Mental Health Quality and Risk Group, which is attended by senior operational managers, service managers team leaders and trainers on 07 September 2023.
This information has been shared with the Trust for wider learning and Care Group relevant business managers and governance leads are review plans to disseminate this information with the emphasis being focused for the specific areas to include training.
The Patient Medical records (RiO) now request that a section to be completed which seeks to ask if they are a veteran. We are in the process of scoping if this can be a mandated question and to also add a hyperlink which will guide the practitioner to the services available. We also plan to add a prompt about ensuring that the patient is supported with the referral if required. This functionality will be audited in 6 months’ time to review accessibility and whether this can be used more widely.
For our Forensic Care Group we have specific pathways and support available for Liaison and Diversion we provide a veterans pathway in custody which includes a mandatory referral to the service – Liaison and Diversion also work closely with and direct individuals to Op Nova in the community. For Offender Health Services, Clinical Specialists provide all the specialist therapeutic input for individuals and groups. They supervise healthcare teams and provide Veteran Awareness training for healthcare teams and all prison staff. This work is supported by Care after Combat who provide support and individual mentorship for veterans making all necessary practical preparations for release. These preparations start as early as a year pre-release to take into account the often lack of or limited civilian living prior to incarceration. This and the through the gate mentorship are significant in the reduction/minimisation/prevention of Adjustment Disorder which many of the men experienced on leaving the Armed Forces and which is often a contributing factor to offending behaviour. The Care after Combat team also co-facilitate the regular groups. They also take on full responsibility and cost for the production, printing and delivery of the Wellbeing/Action packs. Concern that there is too much emphasis on Veterans being solely responsible for self- referral, with no assistance to assist in accessing appropriate services.
The Trust has reflected upon the self-referral pathway for Veteran related services that require a self-referral and recognise that this can present with difficulties in accessing further appropriate services. For example, the impact having to tell a personal and sensitive story repeatedly can be distressing and result in a barrier to such services being accessed.
We recognise that OpCourage remains a self-referral service for Veterans however, as a Trust, we have made the decision to always support this process. This process will be monitored through the audit of veteran patients.
We recognise that a cultural change is required in practice to ensure that where a self-referral is required, that we undertake this in collaboration with the patient to ensure access is not restricted and will be kept under review and oversight.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
In addition, guidance has been written for staff to demonstrate professional curiosity in relation to a service users’ motivation or ability to complete self-referrals. This identifies those who need support to self-refer and clinicians will complete this with the individual or for them if appropriate. This guidance will be included in the updated version of the Local Mental Health Team (LMHT) Standard Operating Procedure (SOP), which will be provided for reference once completed by the end of August 2023. This SOP will incorporate the need to refer Veterans to OpCourage rather than rely on self-referral due to the known difficulty our Veterans have in seeking support. All LMHT staff will be provided with a copy via email and this section will be highlighted in the business meetings. The Trust will need to have assurance that this practice is embedded, therefore an audit will take place over a period of three-month period to identify that staff are exploring if a service user requires support to access self-referral services and for the specific needs of Veterans these referrals are being made on their behalf.
A Veteran folder (Appendix 4) has been developed to help and support referrals for Veterans, this has been shared throughout the Adult Mental Health services And is currently being reviewed by our Mental Health Services for Older Peoples leads and Specialist Services leads to check suitability for patient group and will be shared across Mental Health Services by 18 August 2023.
There was a presentation of Mr Cole’s findings from the inquest at the Mid Notts and Bassetlaw Local Quality and Risk Meeting on Monday 24 July 2023. The learning from this continues to be shared via the business meetings with the teams across the Mental Health and Forensic Care group and Quality & Risk Meetings for wider learning. The emphasis being that support with self-referral will be considered for those who require this.
Concern of a lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
Support has been sought from the Head of Information Governance (IG) to identify the process in which to have any military records released. The Trust was informed by the MoD that the records needed to be formally requested and written consent sought from the individual prior to the application being made. IG colleagues then worked to produce a procedure that would clarify this process for staff with the appropriate contact numbers included for each armed forces and the necessary consent forms enclosed as an appendix.
This procedure (Appendix 5) was approved on 1 August 2023, by the Information Security Forum (ISF) which is the Trust’s IG and IT Security meeting. The procedure has now been published on the Trust’s Intranet Policies Page and it is being explored how this can be added to the veteran demographic section to support staff in reminding them of this new process.
As a result of the development of this, it will be circulated via the Executive Weekly Briefing, the Line Managers’ Bulletin and a link will be added to the Veteran information page on Connect, as well as being included in the next Trustwide Lessons Learned Bulletin. Each Care Group and Care Unit within the Trust has developed their own sharing mechanisms which include discussion in the Care Unit Quality Oversight Group/Quality and Risk Meetings, Service Business Meetings and Team/Ward Meetings with Governance leads ensuring this is included in the relevant agendas.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
Concern as to the quality of the Trust’s Investigation Report and the process of review is not sufficiently robust.
As an organisation we understand the importance of the investigation of Serious Incidents and ensuring that the investigation undertaken is both detailed and robust and provides every opportunity to establish learning to prevent recurrence. In this case our investigation fell below the standard we would have expected and for that we unreservedly apologise for the distress and disruption caused as part of your coronial process. We recognize that there are cases where the standard of report writing and investigating has not been to the level required and have undertaken a number of measures to improve this.
The Mental Health Care Group introduced a panel sign off process which collectively reviews the investigation to provide a higher level of quality assurance and triangulation of information. We envisage our reviewed and strengthened governance will mitigate this risk moving forward.
The learning from the outcome of this preventing future deaths report will be shared as part of on- going training provided to staff undertaking serious incident investigations and those involved within the approval process of investigations.
Incident Investigation Training:
We continue to work with external partners to ensure that staff undertaking serious incident investigations are trained and knowledgeable in investigation techniques. We will continue in our commitment to providing a two-day training event for investigators based on a “Systems Based Approach” (SBA). This approach is advocated by the Patient Safety Incident Response Framework (PSIRF) which will be implemented within NHS Organisations during the Autumn of 2023. The role of SBA is to identify the systems-based problems when an incident occurs, rather than focusing on the individuals involved. Our aim is to provide five two-day Serious Incident Investigation training sessions each year, which enables the opportunity for 125 attendees across those sessions.
Investigation Terms of Reference:
For each serious incident investigation, clear and specific terms of reference are drafted and shared with the Operational Care Groups for comment at draft level before final sign off. They assist with the scope of the investigation and carefully balance ensuring that investigators are clear of the investigation requirements and expectations, and that they are directed to any specific areas to be considered, without being too prescriptive which could risk restricting the panel / investigator in their review.
When completed, terms of reference are signed off as follows:
▪ Concise level terms of reference are signed off within the Operational Care Groups concerned by either Head of Nursing or Associate Director of Nursing ▪ Comprehensive level terms of reference are signed off at Executive Director level.
Quality Assurance of Investigation Reports:
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
We also recognised that we needed to strengthen our overall review of our investigation reports and ensure those individuals who are reviewing/approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose.
Whilst historically we have facilitated a one-off session to assist managers with the quality assurance process, we have now looked to extend our training offer. Therefore, working with our external training providers, we have commissioned a series of Serious Incident Quality Assurance training events during 2023/2024. Between September 2023 and December 2023, we will facilitate six one- day training events.
The course will provide the attendees with skills to critically assess the investigation report and ensure it concentrates on Systems Based outcomes and SMART actions. Our aim is that within the six sessions we can train approximately 150 individuals. The purpose of this training is to provide senior leaders who have responsibility for approving reports with the skills to analyse the report, ensure fairness, that systems-based learning has been applied and that the report and findings reflect the agreed terms of reference and any questions raised by the patient or family. The Trust recognises the need to consider neurodiversity when undertaking investigations. Guidance has now been developed to support investigators to consider individual need, reasonable adjustments, access to learning development and consultation forums.
Review of active Investigations & Inquests:
Whilst we appreciate the need for the work outlined above in terms of the development of our staff in terms of expertise to both undertake investigations, and critically analysis the resulting investing reports. We are also mindful that we have a significant number of completed investigations and upcoming inquests, where we believe we need to undertake a pro-active and objective review of active inquests in the Trust to identify cases where lessons should be learnt and responded to. This will include but not be limited to:
▪ Consideration of learning for the Trust, what lessons have been learnt or need to be learned from this matter. ▪ Ensuring family engagement and compliance with Duty of Candour ▪ A summary of key themes from both current and historical cases which may support improvement work.
I hope the information above provides the assurance that we have and continue to consider your recommendations seriously, and that we are actively seeking to improve the services we provide by implementing the actions outlined.
Please find below the organisational response to the recently received Preventing Future Deaths Report, following the sad death of Mr Cole.
The Matters of Concern raised within the report that relate to Nottinghamshire Healthcare NHS Foundation Trust (thereafter referred to as the Trust):
Concern that the Trust is doing too little to identify and address the risk of suicide for Veterans
Nottinghamshire Healthcare Trust is committed to working collaboratively with patients and staff to prevent suicide and reduce harm. This includes how we work with patients to meet their needs and also equip our workforce to have the right knowledge and skill to respond effectively to suicidality and promote safety. As such, we have a Trustwide Lead for Suicide Prevention, Rachel Lees. This role is a Trustwide role which is responsible for developing and implementing Nottinghamshire Healthcare’s suicide prevention strategy, and working with other partners across the wider system. This role works strategically and clinically to reduce harm and promote safety in relation to suicidality, particularly focusing on training delivery, clinical practice and sharing of learning and key messages. This role provides expert professional advice, guidance and support, working closely with colleagues at all levels of the organisation to develop and improve practice.
Through triangulation of our mortality surveillance data within Nottinghamshire Healthcare Trust, we recognise that the Veteran group do present with factors that impact on their ability to access and Private and Confidential
Ms S Cartwright HM Assistant Coroner for Derby and Derbyshire Saint Katherines House Saint Mary’s Wharf Mansfield Road Derby DE1 3TQ
14 August 2023
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
receive support. Subsequently, they can present with an increased risk of harm. We are committed as an organisation to supporting this patient group and plan to do the following –
1. The three yearly review of the Suicide Strategy is underway and will include a focus on staff awareness of factors which may be affecting different sub-groups of patients and clinical considerations and implications for practice. Specifically, this will reflect the enhanced risk for the veteran patient group from what we have learnt in the Trust and nationally. Our Trust essential training for Suicide Awareness and response will also reflect this.
2. The Trust holds an annual Suicide Prevention conference where this learning will be reflected. Our colleagues in OpCourage and Trust Armed Forces Community Network will also be in attendance and hosting an information stall.
3. The topic for July’s Trustwide Suicide Prevention Champions Network meeting was Veterans and Suicide Prevention with the Operation Lead for OpCourage Midlands attending as the guest speaker to present and share information about the Armed Forces Covenant and OpCourage with colleagues. This meeting was recorded and is being shared Trustwide through various Communications, including being made available on the Trust’s intranet.
4. Rachel Lees will undertake a thematic review over the next 9 months of patients that are veterans and open to services to understand care and treatment and identify any learning. This will be reported through the Quality Operational Group for learning.
Nottinghamshire Healthcare is also a Gold Member of the Armed Forces Covenant and has recently been re-accredited by Veterans Covenant Healthcare Alliance and are "Veteran Aware." (Appendix
1)
Concern that there is a lack of understanding as to the appropriate services to make referrals to for Veterans by the Trust mental health practitioners.
The Trust has taken action to gain knowledge of appropriate Veteran services which are available, and we are able to make referrals to. As a result of this, we have looked to update our mental health practitioners with regards to this information. All this information has been collated from Nottinghamshire Healthcare culture and staff engagement facilitators, who are part of the Veterans’ Network. Leaflets and posters have been provided and are being distributed throughout the Mental Health Care Group and shared with the wider Trust for review and distribution. As part of the information provided is a card that has a QR code on it, practitioners can scan this code and it takes them to the Veteran information pages on the Nottinghamshire Healthcare Trust intranet site ‘Connect.’
Concern that there is a lack of understanding as to the services available for Veterans.
All inpatient sites now display posters that state that ‘We are Proud to be Veteran Aware’ and include the contact details for the Veterans and families service Champions. Posters are being distributed to all community team bases and will be displayed by the end of August; follow up checks are planned. The Trustwide Lessons Learned Bulletin (Appendix 2) contained information relating to Veterans, and this is shared Trustwide and available on the staff intranet site. Specifically in the Adult Mental Health Care Group the monthly communication the ‘Governance Gazette’ in July (Appendix
3), features an article on Veteran services, this communication is distributed to all teams and is discussed in the team meetings which are attended by all levels of staff. The article also has links to
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
Op Courage and Army and You. The Nottinghamshire Healthcare culture and staff engagement facilitators are presenting to the members of the Adult Mental Health Quality and Risk Group, which is attended by senior operational managers, service managers team leaders and trainers on 07 September 2023.
This information has been shared with the Trust for wider learning and Care Group relevant business managers and governance leads are review plans to disseminate this information with the emphasis being focused for the specific areas to include training.
The Patient Medical records (RiO) now request that a section to be completed which seeks to ask if they are a veteran. We are in the process of scoping if this can be a mandated question and to also add a hyperlink which will guide the practitioner to the services available. We also plan to add a prompt about ensuring that the patient is supported with the referral if required. This functionality will be audited in 6 months’ time to review accessibility and whether this can be used more widely.
For our Forensic Care Group we have specific pathways and support available for Liaison and Diversion we provide a veterans pathway in custody which includes a mandatory referral to the service – Liaison and Diversion also work closely with and direct individuals to Op Nova in the community. For Offender Health Services, Clinical Specialists provide all the specialist therapeutic input for individuals and groups. They supervise healthcare teams and provide Veteran Awareness training for healthcare teams and all prison staff. This work is supported by Care after Combat who provide support and individual mentorship for veterans making all necessary practical preparations for release. These preparations start as early as a year pre-release to take into account the often lack of or limited civilian living prior to incarceration. This and the through the gate mentorship are significant in the reduction/minimisation/prevention of Adjustment Disorder which many of the men experienced on leaving the Armed Forces and which is often a contributing factor to offending behaviour. The Care after Combat team also co-facilitate the regular groups. They also take on full responsibility and cost for the production, printing and delivery of the Wellbeing/Action packs. Concern that there is too much emphasis on Veterans being solely responsible for self- referral, with no assistance to assist in accessing appropriate services.
The Trust has reflected upon the self-referral pathway for Veteran related services that require a self-referral and recognise that this can present with difficulties in accessing further appropriate services. For example, the impact having to tell a personal and sensitive story repeatedly can be distressing and result in a barrier to such services being accessed.
We recognise that OpCourage remains a self-referral service for Veterans however, as a Trust, we have made the decision to always support this process. This process will be monitored through the audit of veteran patients.
We recognise that a cultural change is required in practice to ensure that where a self-referral is required, that we undertake this in collaboration with the patient to ensure access is not restricted and will be kept under review and oversight.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
In addition, guidance has been written for staff to demonstrate professional curiosity in relation to a service users’ motivation or ability to complete self-referrals. This identifies those who need support to self-refer and clinicians will complete this with the individual or for them if appropriate. This guidance will be included in the updated version of the Local Mental Health Team (LMHT) Standard Operating Procedure (SOP), which will be provided for reference once completed by the end of August 2023. This SOP will incorporate the need to refer Veterans to OpCourage rather than rely on self-referral due to the known difficulty our Veterans have in seeking support. All LMHT staff will be provided with a copy via email and this section will be highlighted in the business meetings. The Trust will need to have assurance that this practice is embedded, therefore an audit will take place over a period of three-month period to identify that staff are exploring if a service user requires support to access self-referral services and for the specific needs of Veterans these referrals are being made on their behalf.
A Veteran folder (Appendix 4) has been developed to help and support referrals for Veterans, this has been shared throughout the Adult Mental Health services And is currently being reviewed by our Mental Health Services for Older Peoples leads and Specialist Services leads to check suitability for patient group and will be shared across Mental Health Services by 18 August 2023.
There was a presentation of Mr Cole’s findings from the inquest at the Mid Notts and Bassetlaw Local Quality and Risk Meeting on Monday 24 July 2023. The learning from this continues to be shared via the business meetings with the teams across the Mental Health and Forensic Care group and Quality & Risk Meetings for wider learning. The emphasis being that support with self-referral will be considered for those who require this.
Concern of a lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
Support has been sought from the Head of Information Governance (IG) to identify the process in which to have any military records released. The Trust was informed by the MoD that the records needed to be formally requested and written consent sought from the individual prior to the application being made. IG colleagues then worked to produce a procedure that would clarify this process for staff with the appropriate contact numbers included for each armed forces and the necessary consent forms enclosed as an appendix.
This procedure (Appendix 5) was approved on 1 August 2023, by the Information Security Forum (ISF) which is the Trust’s IG and IT Security meeting. The procedure has now been published on the Trust’s Intranet Policies Page and it is being explored how this can be added to the veteran demographic section to support staff in reminding them of this new process.
As a result of the development of this, it will be circulated via the Executive Weekly Briefing, the Line Managers’ Bulletin and a link will be added to the Veteran information page on Connect, as well as being included in the next Trustwide Lessons Learned Bulletin. Each Care Group and Care Unit within the Trust has developed their own sharing mechanisms which include discussion in the Care Unit Quality Oversight Group/Quality and Risk Meetings, Service Business Meetings and Team/Ward Meetings with Governance leads ensuring this is included in the relevant agendas.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
Concern as to the quality of the Trust’s Investigation Report and the process of review is not sufficiently robust.
As an organisation we understand the importance of the investigation of Serious Incidents and ensuring that the investigation undertaken is both detailed and robust and provides every opportunity to establish learning to prevent recurrence. In this case our investigation fell below the standard we would have expected and for that we unreservedly apologise for the distress and disruption caused as part of your coronial process. We recognize that there are cases where the standard of report writing and investigating has not been to the level required and have undertaken a number of measures to improve this.
The Mental Health Care Group introduced a panel sign off process which collectively reviews the investigation to provide a higher level of quality assurance and triangulation of information. We envisage our reviewed and strengthened governance will mitigate this risk moving forward.
The learning from the outcome of this preventing future deaths report will be shared as part of on- going training provided to staff undertaking serious incident investigations and those involved within the approval process of investigations.
Incident Investigation Training:
We continue to work with external partners to ensure that staff undertaking serious incident investigations are trained and knowledgeable in investigation techniques. We will continue in our commitment to providing a two-day training event for investigators based on a “Systems Based Approach” (SBA). This approach is advocated by the Patient Safety Incident Response Framework (PSIRF) which will be implemented within NHS Organisations during the Autumn of 2023. The role of SBA is to identify the systems-based problems when an incident occurs, rather than focusing on the individuals involved. Our aim is to provide five two-day Serious Incident Investigation training sessions each year, which enables the opportunity for 125 attendees across those sessions.
Investigation Terms of Reference:
For each serious incident investigation, clear and specific terms of reference are drafted and shared with the Operational Care Groups for comment at draft level before final sign off. They assist with the scope of the investigation and carefully balance ensuring that investigators are clear of the investigation requirements and expectations, and that they are directed to any specific areas to be considered, without being too prescriptive which could risk restricting the panel / investigator in their review.
When completed, terms of reference are signed off as follows:
▪ Concise level terms of reference are signed off within the Operational Care Groups concerned by either Head of Nursing or Associate Director of Nursing ▪ Comprehensive level terms of reference are signed off at Executive Director level.
Quality Assurance of Investigation Reports:
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
We also recognised that we needed to strengthen our overall review of our investigation reports and ensure those individuals who are reviewing/approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose.
Whilst historically we have facilitated a one-off session to assist managers with the quality assurance process, we have now looked to extend our training offer. Therefore, working with our external training providers, we have commissioned a series of Serious Incident Quality Assurance training events during 2023/2024. Between September 2023 and December 2023, we will facilitate six one- day training events.
The course will provide the attendees with skills to critically assess the investigation report and ensure it concentrates on Systems Based outcomes and SMART actions. Our aim is that within the six sessions we can train approximately 150 individuals. The purpose of this training is to provide senior leaders who have responsibility for approving reports with the skills to analyse the report, ensure fairness, that systems-based learning has been applied and that the report and findings reflect the agreed terms of reference and any questions raised by the patient or family. The Trust recognises the need to consider neurodiversity when undertaking investigations. Guidance has now been developed to support investigators to consider individual need, reasonable adjustments, access to learning development and consultation forums.
Review of active Investigations & Inquests:
Whilst we appreciate the need for the work outlined above in terms of the development of our staff in terms of expertise to both undertake investigations, and critically analysis the resulting investing reports. We are also mindful that we have a significant number of completed investigations and upcoming inquests, where we believe we need to undertake a pro-active and objective review of active inquests in the Trust to identify cases where lessons should be learnt and responded to. This will include but not be limited to:
▪ Consideration of learning for the Trust, what lessons have been learnt or need to be learned from this matter. ▪ Ensuring family engagement and compliance with Duty of Candour ▪ A summary of key themes from both current and historical cases which may support improvement work.
I hope the information above provides the assurance that we have and continue to consider your recommendations seriously, and that we are actively seeking to improve the services we provide by implementing the actions outlined.
Sent To
- Ministry of Defence
- Nottinghamshire Healthcare NHS Foundation Trust
Response Status
Linked responses
2 of 2
56-Day Deadline
31 Jul 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
In 2018 an investigation was commenced into the death of Jonathan “Jonny” Philip Cole [JC], aged 39. The investigation concluded at the end of the Inquest on 25 April 2023. The conclusion of the Inquest was a Narrative Conclusion namely:
Narrative Conclusion a. JC developed Post Traumatic Stress Disorder as a result of at least three traumatic experiences whilst serving in the British Army in Afghanistan on operational tour in 2009 one of which represented a direct threat to his life (where he also suffered physical injuries including hearing loss and tinnitus, shrapnel injuries following a Rocket-Propelled Grenade attack (RPG);
[Note: This service had been with 2 Rifles as part of Operation Herrick 10.]
b. JC had made multiple attempts at suicide and self-harm beginning in January 2010 which were caused or materially contributed to by his unresolved symptoms of PTSD, culminating in a final and successful suicide attempt in August 2018; c. JC did not receive Eye Movement Desensitisation and Reprocessing [EMDR] for those symptoms of Post Traumatic Stress before the summer of 2012, it consisted of no more than 8 sessions of EMDR, which on balance of probability proved latterly to be insufficient albeit the EMDR did provide JC with temporary improvement and some alleviation of symptoms of PTSD in 2012/2013; d. JC’s intrusive memories of the RPG incident were not verified as having been fully processed in the presence of JC’s treating CPN before EMDR was discontinued in 2012 albeit JC had confirmed his belief in 2012 that he had managed to self-process that memory; e. JC received no psychological trauma therapy from 2013 onward up until the time of his death other than the EMDR provided whilst still in the British Army; f. JC left the Army in 2013 without a formal diagnosis of having had PTSD as a result of operational trauma. This was a failure and a diagnosis of PTSD was appropriate at that time; g. JC’’s unresolved symptoms of PTSD caused or contributed to episodic periods of profound mental health crisis, often preceded, and accompanied by, thoughts and attempts to end his life by way of overdose, and latterly hanging. His unresolved symptoms of PTSD also contributed to use of alcohol and drugs to manage the symptoms which in turn led to marital and relationship problems and financial problems; h. JC’s PTSD was accompanied by alcohol and drug use, exacerbating the severity of the underlying condition; i. The continued lack of any official recognition, acknowledgment, or diagnosis on the part of the MOD of his PTSD in the context of JC’s attempts to access financial compensation for his condition, was a failure and materially contributed to a deterioration in his mental health state in the period following his discharge from the Army up until his death and resulted in JC making contact again on 8th June 2018 which was not responded to before his death; j. The Risk assessment and Care Plan completed on 28th January 2018 was inadequate and under estimated the risk of suicide for JC; k. There was a failure to conduct a psychiatric review in January 2018 despite a referral for psychiatric review this failure also caused unnecessary delay before a medication review took place; l. The Risk assessment and Care Plan completed on 14th May 2018 was inadequate and underestimated the risk of suicide; m. JC’s mental health had deteriorated significantly in 2018 and deterioration continued whilst under care of local mental health team and with knowledge that no psychological trauma therapy was being provided; n. By the beginning of 2018 JC’s medication was no longer proving effective as he became increasingly depressed, as well as socially, and occupationally isolated. This led to a change in medication in June 2018, which whilst appropriately indicated was not effectively managed and documented as ineffective on 28th July 2018 when consideration should have been given to appropriately increasing the dose of Paroxetine to assist JC’s low mood; o. Further risk assessments and Care plans should have been completed when Fluoxetine was reduced and removed and Paroxetine introduced; p. A further risk assessment and care plan should have been completed on 26th July 2018 in light of having elicited JC’s recent arrest and changes in his psycho social position including issues of accommodation and financial pressures. This consultation underestimated the risk of suicide. There was a failure of the treating mental health professional to identify that JC was to appear in court 8.8.18. There was a lost opportunity therefore to make contact with the police/ CPS and to liaise with the criminal justice liaison and divergence with relevant information as to the medication review underway and relevant factors of JC’s mental health. There was an under estimation of the risk of suicide on 26.7.18 by not identifying the upcoming court date of 8.8.18 and offering support to JC; q. There was a missed opportunity throughout 2018 to refer JC to the Transition Intervention and Liaison Service [TILS] and the Centre for Trauma Resilience and Growth.
Narrative Conclusion a. JC developed Post Traumatic Stress Disorder as a result of at least three traumatic experiences whilst serving in the British Army in Afghanistan on operational tour in 2009 one of which represented a direct threat to his life (where he also suffered physical injuries including hearing loss and tinnitus, shrapnel injuries following a Rocket-Propelled Grenade attack (RPG);
[Note: This service had been with 2 Rifles as part of Operation Herrick 10.]
b. JC had made multiple attempts at suicide and self-harm beginning in January 2010 which were caused or materially contributed to by his unresolved symptoms of PTSD, culminating in a final and successful suicide attempt in August 2018; c. JC did not receive Eye Movement Desensitisation and Reprocessing [EMDR] for those symptoms of Post Traumatic Stress before the summer of 2012, it consisted of no more than 8 sessions of EMDR, which on balance of probability proved latterly to be insufficient albeit the EMDR did provide JC with temporary improvement and some alleviation of symptoms of PTSD in 2012/2013; d. JC’s intrusive memories of the RPG incident were not verified as having been fully processed in the presence of JC’s treating CPN before EMDR was discontinued in 2012 albeit JC had confirmed his belief in 2012 that he had managed to self-process that memory; e. JC received no psychological trauma therapy from 2013 onward up until the time of his death other than the EMDR provided whilst still in the British Army; f. JC left the Army in 2013 without a formal diagnosis of having had PTSD as a result of operational trauma. This was a failure and a diagnosis of PTSD was appropriate at that time; g. JC’’s unresolved symptoms of PTSD caused or contributed to episodic periods of profound mental health crisis, often preceded, and accompanied by, thoughts and attempts to end his life by way of overdose, and latterly hanging. His unresolved symptoms of PTSD also contributed to use of alcohol and drugs to manage the symptoms which in turn led to marital and relationship problems and financial problems; h. JC’s PTSD was accompanied by alcohol and drug use, exacerbating the severity of the underlying condition; i. The continued lack of any official recognition, acknowledgment, or diagnosis on the part of the MOD of his PTSD in the context of JC’s attempts to access financial compensation for his condition, was a failure and materially contributed to a deterioration in his mental health state in the period following his discharge from the Army up until his death and resulted in JC making contact again on 8th June 2018 which was not responded to before his death; j. The Risk assessment and Care Plan completed on 28th January 2018 was inadequate and under estimated the risk of suicide for JC; k. There was a failure to conduct a psychiatric review in January 2018 despite a referral for psychiatric review this failure also caused unnecessary delay before a medication review took place; l. The Risk assessment and Care Plan completed on 14th May 2018 was inadequate and underestimated the risk of suicide; m. JC’s mental health had deteriorated significantly in 2018 and deterioration continued whilst under care of local mental health team and with knowledge that no psychological trauma therapy was being provided; n. By the beginning of 2018 JC’s medication was no longer proving effective as he became increasingly depressed, as well as socially, and occupationally isolated. This led to a change in medication in June 2018, which whilst appropriately indicated was not effectively managed and documented as ineffective on 28th July 2018 when consideration should have been given to appropriately increasing the dose of Paroxetine to assist JC’s low mood; o. Further risk assessments and Care plans should have been completed when Fluoxetine was reduced and removed and Paroxetine introduced; p. A further risk assessment and care plan should have been completed on 26th July 2018 in light of having elicited JC’s recent arrest and changes in his psycho social position including issues of accommodation and financial pressures. This consultation underestimated the risk of suicide. There was a failure of the treating mental health professional to identify that JC was to appear in court 8.8.18. There was a lost opportunity therefore to make contact with the police/ CPS and to liaise with the criminal justice liaison and divergence with relevant information as to the medication review underway and relevant factors of JC’s mental health. There was an under estimation of the risk of suicide on 26.7.18 by not identifying the upcoming court date of 8.8.18 and offering support to JC; q. There was a missed opportunity throughout 2018 to refer JC to the Transition Intervention and Liaison Service [TILS] and the Centre for Trauma Resilience and Growth.
Circumstances of the Death
On the 9th August 2018 at a location of Old Stone Bridge, Butterley Park, Codnor Park, Ironville, Derbyshire Jonny Cole was found hanging having acted with the intention to end his life. Jonny had PTSD, anxiety, suicidal ideation and was under the care of his local mental health trust. Jonny had not been seen since leaving his home on the afternoon of 7th August 2018 and was due in court on 8th August 2018 to face charges of criminal damage but did not attend.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.