Andrew Shambrook
PFD Report
All Responded
Ref: 2023-0177
All 1 response received
· Deadline: 26 Jul 2023
Coroner's Concerns (AI summary)
The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.
View full coroner's concerns
The MATTER OF CONCERN is as follows. –
The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team
The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team
Responses
Action Planned
The Health Board will review and ratify its Home Treatment Team Operational Policy by 31 January 2024, incorporating the coroner's comments. An interim addendum has been created to address immediate concerns. (AI summary)
The Health Board will review and ratify its Home Treatment Team Operational Policy by 31 January 2024, incorporating the coroner's comments. An interim addendum has been created to address immediate concerns. (AI summary)
View full response
Dear Mr Gittins,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Andrew John Shambrook
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 31 May 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Andrew Shambrook.
I would like to begin by offering my deepest condolences to the family and friends of Mr Shambrook for their loss.
In the Notice, you highlighted your concerns that the health board has no documented or robust policy in relation to decision making criteria and thereafter, future treatment and care pathways when a patient is referred to the Home Treatment Team (HTT).
In response to the Notice, I requested our Mental Health and Learning Disability Division (MHLD) to carefully consider your concerns and provide details of their plans to make our services as safe as possible, taking into account the learning from the inquest.
Firstly, I can confirm that there is an approved Home Treatment Team Operational Policy (MHLD 0035) that has been in use since April 2018. However, this operational policy has exceeded its review date and we are progressing this through the review and ratification process as a priority.
The policy will be reviewed by a working group of key stakeholders, to include home treatment team managers and key clinicians, led by a senior manager. As part of the process of reviewing the Home Treatment Team Operational Policy, the reviewers will be provided with your comments and instructed to ensure that these are fully taken into account.
Once the review is complete, the revised policy will be subject to a period of consultation and will then proceed through the ratification process. Progress on the review and ratification process will be monitored by the divisional policy and procedure development subgroup and any potential delays will be escalated to the divisional senior leadership
Dyddiad / Date: 26 July 2023 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN
Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
team. Assurance will be provided on a monthly basis to the corporate regulatory group. I expect this process to be complete by 31 January 2024 and I will be happy to share with you a copy of the refreshed policy at that time.
As an interim measure, MHLD have provided an addendum to the policy to ensure the concerns noted at the inquest are addressed. The addendum to the Policy will be shared across MHLD to ensure that there is consistency across all areas and I have enclosed a copy of this for your reference.
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself and Mr Shambrook’s family are being addressed.
We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Mr Shambrook for their loss.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Andrew John Shambrook
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 31 May 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Andrew Shambrook.
I would like to begin by offering my deepest condolences to the family and friends of Mr Shambrook for their loss.
In the Notice, you highlighted your concerns that the health board has no documented or robust policy in relation to decision making criteria and thereafter, future treatment and care pathways when a patient is referred to the Home Treatment Team (HTT).
In response to the Notice, I requested our Mental Health and Learning Disability Division (MHLD) to carefully consider your concerns and provide details of their plans to make our services as safe as possible, taking into account the learning from the inquest.
Firstly, I can confirm that there is an approved Home Treatment Team Operational Policy (MHLD 0035) that has been in use since April 2018. However, this operational policy has exceeded its review date and we are progressing this through the review and ratification process as a priority.
The policy will be reviewed by a working group of key stakeholders, to include home treatment team managers and key clinicians, led by a senior manager. As part of the process of reviewing the Home Treatment Team Operational Policy, the reviewers will be provided with your comments and instructed to ensure that these are fully taken into account.
Once the review is complete, the revised policy will be subject to a period of consultation and will then proceed through the ratification process. Progress on the review and ratification process will be monitored by the divisional policy and procedure development subgroup and any potential delays will be escalated to the divisional senior leadership
Dyddiad / Date: 26 July 2023 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN
Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
team. Assurance will be provided on a monthly basis to the corporate regulatory group. I expect this process to be complete by 31 January 2024 and I will be happy to share with you a copy of the refreshed policy at that time.
As an interim measure, MHLD have provided an addendum to the policy to ensure the concerns noted at the inquest are addressed. The addendum to the Policy will be shared across MHLD to ensure that there is consistency across all areas and I have enclosed a copy of this for your reference.
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself and Mr Shambrook’s family are being addressed.
We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Mr Shambrook for their loss.
Sent To
- Betsi Cadwaladr University Health Board
Response Status
Linked responses
1 of 1
56-Day Deadline
26 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
On the 28th of March 2022 I commenced an investigation into the death of Andrew John Shambrook (DOB 17.2.77 DOD 27.3.22). The investigation concluded at the end of the inquest on the 28th of April 2023. The cause of death was recorded as being due to 1(a) Hanging and the conclusion of the inquest was that of suicide.
The evidence indicated that Mr Shambrook was under the care of the mental health services and that there had been a referral to the Home Treatment Team, however he did not meet their criteria for treatment.
The evidence indicated that Mr Shambrook was under the care of the mental health services and that there had been a referral to the Home Treatment Team, however he did not meet their criteria for treatment.
Circumstances of the Death
The circumstances of the death are that Mr Shambrook took his own life by hanging on the 27th of March 2022.
Action Should Be Taken
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Apply best offer principle equally in GLOS
Post Office Horizon Inquiry
Outdated Operational Guidance
Post Office to engage in negotiations during HSSA appeal period
Post Office Horizon Inquiry
Outdated Operational Guidance
Set deadline for HSS claims with guidance on late applications
Post Office Horizon Inquiry
Outdated Operational Guidance
Clarify whether HCRS and OCS assessment processes differ
Post Office Horizon Inquiry
Outdated Operational Guidance
Establish standing public body to administer future redress schemes
Post Office Horizon Inquiry
Outdated Operational Guidance
Devise redress process for affected family members
Post Office Horizon Inquiry
Outdated Operational Guidance
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.