Joy Burgess
PFD Report
All Responded
Ref: 2022-0038
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Other related deaths
Suicide (from 2015)
All 1 response received
· Deadline: 1 Apr 2022
Coroner's Concerns (AI summary)
Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.
View full coroner's concerns
1. The Court heard evidence that the mental health ward environment could be 'chaotic' (in the words ofone Consultant Psychiatrist) and that resources and demands on inpatient beds were such that staffwere not always able to care for patients in a suitable environment. It is a matter of concern that mental health patients are, on occasion, cared for in an environment which is very obviously not conducive to recovery.
2. The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral.
2. The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral.
Responses
Action Planned
The Department of Health and Social Care references NHS England's consultation on new waiting time standards for mental health services and states they are working on the next steps following the consultation. (AI summary)
The Department of Health and Social Care references NHS England's consultation on new waiting time standards for mental health services and states they are working on the next steps following the consultation. (AI summary)
View full response
Dear Mr Morris,
Thank you for your correspondence of 4 February 2022, to the then Secretary of State for Health and Social Care, Sajid Javid, regarding the death of Joy Burgess. I am replying as Minister with responsibility for Mental Health, and thank you for the additional time allowed.
I would like to begin by offering my deepest condolences to the family and loved ones of Mrs Burgess. Your report raises important concerns regarding the quality and suitability of care for those suffering from mental health problems, and long waiting times for psychological therapies. It is, of course, vital that we take learnings, where they are identified, to improve the NHS care, and I am grateful to you for bringing these matters to my attention.
In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC). I am also informed that Pennine Care NHS Foundation Trust (PCFT) have produced an investigation report, in line with the NHS Serious Incident Framework, and have provided evidence at the inquest, and that the CQC has accepted the findings of the report.
We recognise the importance of providing an environment that feels safe and comfortable for people receiving treatment in mental health inpatient care. I understand that in their Concise Investigation Report, the Trust acknowledged that Ms Burgess’s experience on the Taylor ward fell short of the expected standard. You may wish to note that the Government is committed to upgrading the physical environment for inpatient mental health care, and we are already taking steps to modernise inpatient environments and improve patient experience. We are investing more than £400 million over the 4 years up to 2024/25 to eradicate dormitory accommodation from mental health facilities to improve
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care
39 Victoria Street London SW1H 0EU
the safety, privacy and dignity of patients suffering with mental illness.
In addition, we are investing £150 million for significant improvements to the mental health estate, including investing in NHS mental health facilities linked to accident and emergency departments, enhancing patient safety in mental health units, and new mental health ambulances.
You noted that Ms Burgess was on a lengthy waiting-list to access psychological therapy at the time of her death and were concerned that other patients are continuing to wait significant lengths of time for care.
The pandemic has had an impact on the mental health and wellbeing of many people, which has caused increased demand for mental health services. In order to help address this, we provided an extra £500 million in 2021/22 to accelerate our expansion plans and address waiting times for mental health services, which will provide more people with the mental health support they need and invest in the NHS workforce. This funding included £110 million to expand adult mental health services - including talking and psychological therapies, implementing the community mental health framework, investment in crisis services and maintaining the delivery of the 24/7 urgent mental health helplines stood up earlier in the pandemic, as well as additional investment in suicide prevention programmes.
The NHS Long Term Plan committed that, by 2023/24 we will invest almost £1 billion extra in community mental health care for adults with severe mental illness. You may also wish to know that work is also ongoing to expand and improve mental health crisis care provision. This includes improving the operation of all age 24/7 crisis lines, crisis resolution home treatment teams, and mental health liaison services in A&E departments.
With regards to those people with more complex mental health needs, who are waiting for treatment, NHS England consulted in 2021 on the potential to introduce five new waiting time standards as part of its clinically-led review of NHS access standards. The proposals included:
• Patients referred from Accident and Emergency should be seen face to face within one hour, by mental health liaison or children and young people’s equivalent service
• For a ‘very urgent’ referral to a community based mental health crisis service, a patient should be seen within four hours from referral, for all age groups
• For an ‘urgent’ referral to a community based mental health crisis service, a patient should be seen within 24 hours from referral, across all ages
• Children, young people and their families/carers presenting to community-based mental health services, should start to receive care within four weeks from referral; and
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care
39 Victoria Street London SW1H 0EU
• Adults and older adults presenting to community-based mental health services should start to receive help within four weeks from referral. NHS England published the outcomes of its consultation in February 20221, and we are now working with them on the next steps.
I hope this response reassures you that the government and the NHS take mental health seriously and that action is being taken to address the quality and timeliness of care.
Kind regards,
MARIA CAULFIELD
1 https://www.england.nhs.uk/2021/07/nhs-england-proposes-new-mental-health-access-standards/
Thank you for your correspondence of 4 February 2022, to the then Secretary of State for Health and Social Care, Sajid Javid, regarding the death of Joy Burgess. I am replying as Minister with responsibility for Mental Health, and thank you for the additional time allowed.
I would like to begin by offering my deepest condolences to the family and loved ones of Mrs Burgess. Your report raises important concerns regarding the quality and suitability of care for those suffering from mental health problems, and long waiting times for psychological therapies. It is, of course, vital that we take learnings, where they are identified, to improve the NHS care, and I am grateful to you for bringing these matters to my attention.
In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC). I am also informed that Pennine Care NHS Foundation Trust (PCFT) have produced an investigation report, in line with the NHS Serious Incident Framework, and have provided evidence at the inquest, and that the CQC has accepted the findings of the report.
We recognise the importance of providing an environment that feels safe and comfortable for people receiving treatment in mental health inpatient care. I understand that in their Concise Investigation Report, the Trust acknowledged that Ms Burgess’s experience on the Taylor ward fell short of the expected standard. You may wish to note that the Government is committed to upgrading the physical environment for inpatient mental health care, and we are already taking steps to modernise inpatient environments and improve patient experience. We are investing more than £400 million over the 4 years up to 2024/25 to eradicate dormitory accommodation from mental health facilities to improve
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care
39 Victoria Street London SW1H 0EU
the safety, privacy and dignity of patients suffering with mental illness.
In addition, we are investing £150 million for significant improvements to the mental health estate, including investing in NHS mental health facilities linked to accident and emergency departments, enhancing patient safety in mental health units, and new mental health ambulances.
You noted that Ms Burgess was on a lengthy waiting-list to access psychological therapy at the time of her death and were concerned that other patients are continuing to wait significant lengths of time for care.
The pandemic has had an impact on the mental health and wellbeing of many people, which has caused increased demand for mental health services. In order to help address this, we provided an extra £500 million in 2021/22 to accelerate our expansion plans and address waiting times for mental health services, which will provide more people with the mental health support they need and invest in the NHS workforce. This funding included £110 million to expand adult mental health services - including talking and psychological therapies, implementing the community mental health framework, investment in crisis services and maintaining the delivery of the 24/7 urgent mental health helplines stood up earlier in the pandemic, as well as additional investment in suicide prevention programmes.
The NHS Long Term Plan committed that, by 2023/24 we will invest almost £1 billion extra in community mental health care for adults with severe mental illness. You may also wish to know that work is also ongoing to expand and improve mental health crisis care provision. This includes improving the operation of all age 24/7 crisis lines, crisis resolution home treatment teams, and mental health liaison services in A&E departments.
With regards to those people with more complex mental health needs, who are waiting for treatment, NHS England consulted in 2021 on the potential to introduce five new waiting time standards as part of its clinically-led review of NHS access standards. The proposals included:
• Patients referred from Accident and Emergency should be seen face to face within one hour, by mental health liaison or children and young people’s equivalent service
• For a ‘very urgent’ referral to a community based mental health crisis service, a patient should be seen within four hours from referral, for all age groups
• For an ‘urgent’ referral to a community based mental health crisis service, a patient should be seen within 24 hours from referral, across all ages
• Children, young people and their families/carers presenting to community-based mental health services, should start to receive care within four weeks from referral; and
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care
39 Victoria Street London SW1H 0EU
• Adults and older adults presenting to community-based mental health services should start to receive help within four weeks from referral. NHS England published the outcomes of its consultation in February 20221, and we are now working with them on the next steps.
I hope this response reassures you that the government and the NHS take mental health seriously and that action is being taken to address the quality and timeliness of care.
Kind regards,
MARIA CAULFIELD
1 https://www.england.nhs.uk/2021/07/nhs-england-proposes-new-mental-health-access-standards/
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
1 Apr 2022
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 25th June 2021, Anna Morris, Assistant Coroner, opened an inquest into the death ofJoy Burgess who died on 9th June 2021 aged 56 years. The investigation concluded at the end ofthe inquest which I heard on 4th February 2022. A post-mortem examination undertaken by Consultant Pathologist, determined Ms Burgess died as the result ofmultiple injuries. By way ofconclusion, I recorded that Ms Burgess died as a consequence of suicide.
Circumstances of the Death
Joy Burgess died from multiple injuries sustained as a consequence of
. Ms Burgess had a long history ofcomplex mental health difficulties and had been under the Community Mental Health Team. In addition to being prescribed medication, Ms Burgess was on a lengthy waiting-list to access psychological therapies. In May 2021 , Ms Burgess's mental health deteriorated with her developing an increasing array ofdepressive symptoms, anxiety which was providing difficult to manage in the community, and thoughts ofself-harm.
She was admitted to hospital as a voluntary patient, but took her own discharge a number ofdays later. Ms Burgess disclosed to staff that this was because she found the ward environment was busy and extremely noisy. Ms Burgess described being disturbed by the screams ofsome ofthe patients, and considered being on the ward was making her feel worse. Upon leaving the ward, Ms Burgess was followed-up by her Care Co-Ordinator and the Home Treatment Team.
. Ms Burgess had a long history ofcomplex mental health difficulties and had been under the Community Mental Health Team. In addition to being prescribed medication, Ms Burgess was on a lengthy waiting-list to access psychological therapies. In May 2021 , Ms Burgess's mental health deteriorated with her developing an increasing array ofdepressive symptoms, anxiety which was providing difficult to manage in the community, and thoughts ofself-harm.
She was admitted to hospital as a voluntary patient, but took her own discharge a number ofdays later. Ms Burgess disclosed to staff that this was because she found the ward environment was busy and extremely noisy. Ms Burgess described being disturbed by the screams ofsome ofthe patients, and considered being on the ward was making her feel worse. Upon leaving the ward, Ms Burgess was followed-up by her Care Co-Ordinator and the Home Treatment Team.
Copies Sent To
and Pennine Care NHS Foundation Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.