Hannah Bampfylde
PFD Report
All Responded
Ref: 2021-0136
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
All 1 response received
· Deadline: 30 Jun 2021
Coroner's Concerns (AI summary)
Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy lacked clarity on re-booking appointments and escalating non-attendance, allowing newly referred patients to slip through the system.
View full coroner's concerns
Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place. Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
Consideration should be given to whether any steps can be taken to address the above concerns.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place. Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
Consideration should be given to whether any steps can be taken to address the above concerns.
Responses
Action Taken
Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. The requirement to notify the GP is stated in their Active Engagement Did Not Attend (DNA) Management Policy; weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS. (AI summary)
Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. The requirement to notify the GP is stated in their Active Engagement Did Not Attend (DNA) Management Policy; weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS. (AI summary)
View full response
Dear Ms Loxton I write in response to your letter of 5 May 2021 in which you raised a concern about follow - up for initial assessment appointments with GP’s and patients. Your concern was raised in accordance with Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroner's (Investigations) Regulations 2013 following the inquest of Ms Hannah Bampfylde in a Regulation 28 Report. I would very much like to start by expressing my sincere condolences to Hannah’s family for their very sad loss. I have read Hannah’s Carenotes and can see the difficulties the Horsham Assessment and Treatment Service had in trying to get Hannah to engage with the service. I have also heard from the audio transcript of the inquest, the proceedings as they occurred in real time. I can confirm the evidence provided to you by , who spoke to the Trust’s SI, was accurate in relation to the measures we have taken as a Trust, since September 2020, to manage routine referrals. Our response to your concern (in bold below) is as follows: -
1. Appointments are not automatically re-booked when a person has failed to attend an appointment. Our Active Engagement Did Not Attend (DNA) Management Policy (attached) states that where a person fails to attend an appointment, the clinician should make an assessment of any risk posed by reviewing the care and contingency Ms Loxton C/o Sarah Church Sent by email:
2
plans and should decide and document the course of action. This is a clinical risk-based decision.
Our North West Sussex Referral, Triage, Assessment and Allocation Process Map (also attached) states that the assessor is to contact the patient to determine the reasons why the patient did not attend. You will recall that contact was attempted several times in Hannah’s case, unfortunately with no response. Following any contact/non-contact made, the assessor will then discuss with the Referrals Coordinator and document the decision and plan on the patients’ Carenotes. The assessors name is now updated on the Carenotes if another assessment has been planned/booked.
The above process was discussed in the Horsham Assessment and Treatment Service zoning meeting on 12th May 2020. The Team have been given the direction that after 3 appointments DNA’d/not attended, they will consider discussion with their shift supervisor, a cold call to the patient and/or a letter to be sent to the patient, copying in the patients’ GP. The aim is to attempt engagement with the patient. Where the patient repeatedly fails to engage despite the efforts made.
2. It is not clear who should re-book appointments when a person has failed to attend (administration or assessors)
Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. This measure reduces the risk of a patient not being followed up as highlighted the North West Sussex Referral, Triage, Assessment and Allocation Process Map attached.
3. GP’s are not routinely notified if a person has not attended an appointment with the Horsham ATS, meaning the GP would be unaware the person was not receiving input from the Horsham ATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
The requirement to notify the GP is stated in our Active Engagement Did Not Attend (DNA) Management Policy. This requirement was outlined in our Serious Incident Report as an action. The action is complete and the practice embedded. Weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS due to repeated non-attendance and or engagement.
3
The safety of patients referred to us is of paramount importance to the Trust. Our service cannot coerce engagement as the desire to engage must come from the patient themselves, particularly when they are capacitous, like Hannah was. However, it is important for our systems to be effective and to ensure that no patient ‘falls’ between services. I trust this letter demonstrates to you and Hannah’s family the action we took to strengthen our systems. I will ensure we audit compliance with this over forthcoming months.
1. Appointments are not automatically re-booked when a person has failed to attend an appointment. Our Active Engagement Did Not Attend (DNA) Management Policy (attached) states that where a person fails to attend an appointment, the clinician should make an assessment of any risk posed by reviewing the care and contingency Ms Loxton C/o Sarah Church Sent by email:
2
plans and should decide and document the course of action. This is a clinical risk-based decision.
Our North West Sussex Referral, Triage, Assessment and Allocation Process Map (also attached) states that the assessor is to contact the patient to determine the reasons why the patient did not attend. You will recall that contact was attempted several times in Hannah’s case, unfortunately with no response. Following any contact/non-contact made, the assessor will then discuss with the Referrals Coordinator and document the decision and plan on the patients’ Carenotes. The assessors name is now updated on the Carenotes if another assessment has been planned/booked.
The above process was discussed in the Horsham Assessment and Treatment Service zoning meeting on 12th May 2020. The Team have been given the direction that after 3 appointments DNA’d/not attended, they will consider discussion with their shift supervisor, a cold call to the patient and/or a letter to be sent to the patient, copying in the patients’ GP. The aim is to attempt engagement with the patient. Where the patient repeatedly fails to engage despite the efforts made.
2. It is not clear who should re-book appointments when a person has failed to attend (administration or assessors)
Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. This measure reduces the risk of a patient not being followed up as highlighted the North West Sussex Referral, Triage, Assessment and Allocation Process Map attached.
3. GP’s are not routinely notified if a person has not attended an appointment with the Horsham ATS, meaning the GP would be unaware the person was not receiving input from the Horsham ATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
The requirement to notify the GP is stated in our Active Engagement Did Not Attend (DNA) Management Policy. This requirement was outlined in our Serious Incident Report as an action. The action is complete and the practice embedded. Weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS due to repeated non-attendance and or engagement.
3
The safety of patients referred to us is of paramount importance to the Trust. Our service cannot coerce engagement as the desire to engage must come from the patient themselves, particularly when they are capacitous, like Hannah was. However, it is important for our systems to be effective and to ensure that no patient ‘falls’ between services. I trust this letter demonstrates to you and Hannah’s family the action we took to strengthen our systems. I will ensure we audit compliance with this over forthcoming months.
Sent To
- Sussex Partnership NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
30 Jun 2021
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
The inquest into the death of Hannah Bampfylde was opened on 30th April 2020. It was resumed on 30th March and concluded on 28th April 2021. I found the medical cause of death to be: 1a. Hanging
I determined that Hannah took her own life. Hannah had taken an overdose of medication in October 2019, as a result of which she was referred by the Psychiatric Liaison Nurse who assessed her at East Surrey Hospital to Time to Talk service, but this referral was rejected by Time to Talk as Hannah’s suicide attempt rendered her condition too severe for the service. Her GP then made a routine referral to Horsham Assessment & Treatment Service (“HATS”), part of Sussex Partnership NHS Foundation Trust (“the Trust”), for Mental Health Service input. Two assessment appointments were made for Hannah; on 26th November 2019 and 4th December 2019 (subsequently changed to 6th December 2019). These appointments were recorded as DNAs, although I heard evidence Hannah had moved address so may not have received appointment letters and, when notified of the change in the second appointment by text message, was only told the time of this on the day itself when she would already have been at work. No further appointment was made and therefore no action was effectively taken to progress Hannah’s referral until March 2020, when the Assessor noted Hannah’s name remained on her caseload and discussed her with the Referrals Coordinator at HATS. An Opt-in /Contact letter was sent on 4th March 2020 informing Hannah that, as she was recorded as having failed to attend two appointments, she would be discharged back to the care of her GP unless she made contact by 20th March 2020. Hannah was herself made aware of this when she attended the Urgent Treatment Centre at Crawley Hospital on 5th March 2020 reporting volatile mood and was seen by a Specialist Nurse Practitioner in Psychiatry, who notified her of the letter and advised her to contact HATS. Hannah was subsequently discharged back to the care of her GP on 1st April 2020 without having been assessed by HATS.
I determined that Hannah took her own life. Hannah had taken an overdose of medication in October 2019, as a result of which she was referred by the Psychiatric Liaison Nurse who assessed her at East Surrey Hospital to Time to Talk service, but this referral was rejected by Time to Talk as Hannah’s suicide attempt rendered her condition too severe for the service. Her GP then made a routine referral to Horsham Assessment & Treatment Service (“HATS”), part of Sussex Partnership NHS Foundation Trust (“the Trust”), for Mental Health Service input. Two assessment appointments were made for Hannah; on 26th November 2019 and 4th December 2019 (subsequently changed to 6th December 2019). These appointments were recorded as DNAs, although I heard evidence Hannah had moved address so may not have received appointment letters and, when notified of the change in the second appointment by text message, was only told the time of this on the day itself when she would already have been at work. No further appointment was made and therefore no action was effectively taken to progress Hannah’s referral until March 2020, when the Assessor noted Hannah’s name remained on her caseload and discussed her with the Referrals Coordinator at HATS. An Opt-in /Contact letter was sent on 4th March 2020 informing Hannah that, as she was recorded as having failed to attend two appointments, she would be discharged back to the care of her GP unless she made contact by 20th March 2020. Hannah was herself made aware of this when she attended the Urgent Treatment Centre at Crawley Hospital on 5th March 2020 reporting volatile mood and was seen by a Specialist Nurse Practitioner in Psychiatry, who notified her of the letter and advised her to contact HATS. Hannah was subsequently discharged back to the care of her GP on 1st April 2020 without having been assessed by HATS.
Circumstances of the Death
Hannah Bampfylde was found hanging deceased in the garage of her Mother’s home address, where she had been staying, in Horley, Surrey. A note was found dated 26th March 2020 in Hannah’s bedroom in which she stated she could not carry on living.
Copies Sent To
1. See names in paragraph 1 above
Signed
ANNA LOXTON
DATED this 5th day of May 2021
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.