David Fowler
PFD Report
All Responded
Ref: 2019-0450
Alcohol, drug and medication related deaths
Care Home Health related deaths
Community health care and emergency services related deaths
Mental Health related deaths
All 1 response received
· Deadline: 2 Mar 2020
Coroner's Concerns (AI summary)
The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.
View full coroner's concerns
In David's case, no steps were taken to invite (or other family member) to the MDT meeting on the 18u December 2018 When the decision was made by the Responsible Clinician to remove David from the confines of section 3 (and section
17) of the Mental Health Act 1983_ It is a requirement of the Mental Health Act 1983 that the nearest relative is informed: Further; family views were not sought regarding the decision to lift the section in any other way_ At the inquest, staff remained unclear between themselves as to whose responsibility it was to inform the family_ Whilst was informed that Policy has been drafted and is in the process of being ratified, it remained the case that there was no formal in place covering contact with families in respect of the above decisions andlor in respect of inviting family members to MDTs more generally _ was further concerned that there was on-going confusion between witnesses (in particular the Acting Manager and the Responsible Clinician) as to who is tasked with informing the family of MDTs ad of any potential decision to remove a "section"
17) of the Mental Health Act 1983_ It is a requirement of the Mental Health Act 1983 that the nearest relative is informed: Further; family views were not sought regarding the decision to lift the section in any other way_ At the inquest, staff remained unclear between themselves as to whose responsibility it was to inform the family_ Whilst was informed that Policy has been drafted and is in the process of being ratified, it remained the case that there was no formal in place covering contact with families in respect of the above decisions andlor in respect of inviting family members to MDTs more generally _ was further concerned that there was on-going confusion between witnesses (in particular the Acting Manager and the Responsible Clinician) as to who is tasked with informing the family of MDTs ad of any potential decision to remove a "section"
Responses
Action Taken
The TRU revised policies and procedures for critical decision-making, multidisciplinary team communications, mental capacity assessments, care coordination, communication with family and statutory services, and aftercare/discharge planning. The Responsible Clinician made a referral to the General Medical Council and undertook further professional development. (AI summary)
The TRU revised policies and procedures for critical decision-making, multidisciplinary team communications, mental capacity assessments, care coordination, communication with family and statutory services, and aftercare/discharge planning. The Responsible Clinician made a referral to the General Medical Council and undertook further professional development. (AI summary)
View full response
Dear Ms. Galloway
Re: Response to Regulation 28: Report to Prevent Future Deaths, in relation to the inquest of Mr. David Richard Fowler Deceased.
I am writing to provide a formal response to the Regulation 28 for the prevention of future deaths issued to the TRU (Transitional Rehabilitation Unit) LTD following the inquest of Mr. David Fowler. I confirm the following action has been taken in response to the regulation issued:
There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This has included a revision of procedures regarding multidisciplinary team communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process.
I have attached this revised policy for the organisation involving all TRU services, MH28 Care Planning and Care Coordination policy, as this outlines and clarifies several procedures that are operational in relation to:
1. Communication with family members and statutory professionals.
2. Decision making protocol including a new decision making checklist as seen in appendix 6.0 of the policy, which outlines clear protocol relating to assessment of mental capacity.
3. A revised care planning review form that is utilised for every meeting reviewing a client’s care as outlined in appendix 5.0 and formalises feedback on an ongoing basis from family during weekly, six weekly and formal
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conference meetings.
4. Clarification of roles and responsibilities across team members in relation to care coordination and communication to family members including the Nearest Relative for individuals detained under the Mental Health Act and the next of kin for all individuals.
5. A clear transition planning process to ensure continuity of communication with families and continuity of care planning if an individual transitions from one service to another within TRU.
6. A clear discharge planning process as outlined in the care planning framework summary of appendix 1.0 and within the body of the policy. This includes the aftercare planning procedures undertaken in advance of any individual discharging from a legal framework, including the Mental Health Act, and/or any broader discharge from the service.
I have also attached two revised policies specific to care planning policies for adults detained under the Mental Health Act most relevant to this regulation. These are the MH12 Section 117 planning policy and the MH10 Communicating to family and external parties’ policy for people under the Mental Health Act. These two policies outline specifically:
1. The clear and non-negotiable procedure and structure of a 117 planning meeting clearly involving family and statutory professionals.
2. Clarification over specific contact between the treating team and the Nearest Relative in relation to ensuring family members know when care planning reviews are taking place, ensuring their wishes and views are well represented if the family member does not wish or is unable to attend and to ensure clear and timely feedback from any meeting and certainly in respect to any planned discharges from the Mental Health Act.
These two policies specific to individuals detained under the Mental Health Act are supplemented by the broader MH28 policy as outlined above in supporting robust care planning and coordination.
I confirm there have been regular reviews of these procedures since the inquest and an audit framework has been devised to monitor continued compliance and service delivery in these areas including direct audit of the stages outlined in appendix 1.0 (care planning framework).
I also confirm the Responsible Clinician involved in this case has made a referral to the General Medical Council and the individual has undertaken further action related to professional development, supervision and training.
I believe the revisions above directly address, and resolve, the concerns raised through the Regulation 28.
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I hope the attached information is informative and outlines these improvements although please let me know if you require further information.
Re: Response to Regulation 28: Report to Prevent Future Deaths, in relation to the inquest of Mr. David Richard Fowler Deceased.
I am writing to provide a formal response to the Regulation 28 for the prevention of future deaths issued to the TRU (Transitional Rehabilitation Unit) LTD following the inquest of Mr. David Fowler. I confirm the following action has been taken in response to the regulation issued:
There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This has included a revision of procedures regarding multidisciplinary team communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process.
I have attached this revised policy for the organisation involving all TRU services, MH28 Care Planning and Care Coordination policy, as this outlines and clarifies several procedures that are operational in relation to:
1. Communication with family members and statutory professionals.
2. Decision making protocol including a new decision making checklist as seen in appendix 6.0 of the policy, which outlines clear protocol relating to assessment of mental capacity.
3. A revised care planning review form that is utilised for every meeting reviewing a client’s care as outlined in appendix 5.0 and formalises feedback on an ongoing basis from family during weekly, six weekly and formal
2 | P a g e
conference meetings.
4. Clarification of roles and responsibilities across team members in relation to care coordination and communication to family members including the Nearest Relative for individuals detained under the Mental Health Act and the next of kin for all individuals.
5. A clear transition planning process to ensure continuity of communication with families and continuity of care planning if an individual transitions from one service to another within TRU.
6. A clear discharge planning process as outlined in the care planning framework summary of appendix 1.0 and within the body of the policy. This includes the aftercare planning procedures undertaken in advance of any individual discharging from a legal framework, including the Mental Health Act, and/or any broader discharge from the service.
I have also attached two revised policies specific to care planning policies for adults detained under the Mental Health Act most relevant to this regulation. These are the MH12 Section 117 planning policy and the MH10 Communicating to family and external parties’ policy for people under the Mental Health Act. These two policies outline specifically:
1. The clear and non-negotiable procedure and structure of a 117 planning meeting clearly involving family and statutory professionals.
2. Clarification over specific contact between the treating team and the Nearest Relative in relation to ensuring family members know when care planning reviews are taking place, ensuring their wishes and views are well represented if the family member does not wish or is unable to attend and to ensure clear and timely feedback from any meeting and certainly in respect to any planned discharges from the Mental Health Act.
These two policies specific to individuals detained under the Mental Health Act are supplemented by the broader MH28 policy as outlined above in supporting robust care planning and coordination.
I confirm there have been regular reviews of these procedures since the inquest and an audit framework has been devised to monitor continued compliance and service delivery in these areas including direct audit of the stages outlined in appendix 1.0 (care planning framework).
I also confirm the Responsible Clinician involved in this case has made a referral to the General Medical Council and the individual has undertaken further action related to professional development, supervision and training.
I believe the revisions above directly address, and resolve, the concerns raised through the Regulation 28.
3 | P a g e
I hope the attached information is informative and outlines these improvements although please let me know if you require further information.
Sent To
- TRU
Response Status
Linked responses
1 of 1
56-Day Deadline
2 Mar 2020
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 2d January 2019 /| commenced an investigation into the death of David Richard Fowler. An inquest was opened on the 4lh January 2019 The investigation concluded following a 5-day inquest at Bolton Coroner s Court on the 20ih December 2019 and the conclusion was one of Suicide. The Medical Cause of Death was 1a Multiple injuries
Circumstances of the Death
David Fowler ("David") had a significant history of mental illness From around 1999, David had developed problems with both illicit drugs and alcohol consumption: In Or around 2003, David suffered significant brain injury due to a assault: That brain injury caused or seriously exacerbated a Personality Disorder: The combination of the brain injury and Personality Disorder meant that David was impulsive and his alcohol and drug misuse problems became more extensive and difficult to manage. In April 2017 , David was referred to and accepted for specialist rehabilitation at the Transitional Rehabilitation Unit ("TRU"), which was funded by the Iocal Clinical Commissioning Group: At this stage, David was resident at Newton Unit (a locked rehabilitation unit) and detained under section 3 of the Mental Health Act 1983. He later spent time at Lowton Unit (an open rehabilitation ward) before moving to Ashton Cross on the 12th March 2018. Ashton Cross was a pre-community placement: David remained under section 3 of Mental Health Act 1983 but had been granted section 17 leave with a condition that he reside at Ashton Cross. Throughout his time at TRU, David received significant therapeutic input including help with problem solving and impulsivity , counselling and planning: There were periods where David showed improvement and other periods where he would abscond from the various units and consume alcohol and illicit drugs. On the 18h December 2018, an inappropriate decision was taken (following Multidisciplinary Disciplinary Team Meeting ("MDT")) that David's "section 3" (and parasitic "section 17' provisions) would be removed It was the view of the instructed expert Psychiatrist that the "section" should not have been lifted until there was a plan in the place regarding his community placement and care going forward: As a result of the decision of the Responsible Clinician at the MDT, David became resident at Ashton Cross with no legal framework in place and with no community plan in place for his future The views of David's family were not sought prior to the decision to lift the section on the 18th December 2018. Further; Davids family was not invited to attend the MDT meeting on the 18th December 2018. David left Ashton Cross on the 20t December 2018 and was returned by police o the 23rd December 2018. David had consumed alcohol and drugs during this period and been arrested for a criminal offence: His behaviour was escalating but the lack of any legal framework meant that TRU had limited control over him: On the 26th December 2018, David left Ashton Cross at 1.30 pm with the intention of placing a bet on the races_ He was a voluntary client at Ashton cross and was entitled to come and go as he pleased. At approximately pm David fell backwards from motorway bridge at junction 24 of the M6 from the A58 (Liverpool Road) In the moments prior to taking those actions, David likely formed an intention to end his own life by falling from the bridge. He had not formed any specific intention to end his own life to that: David died as a consequence of multiple injuries sustained after he fell from a Motorway Bridge, with the intention of ending his own life: The inappropriate decision to revoke his detention under section 3 of the Mental Health Act 1983 (eight days prior to his death) likely contributed to his death: This was the evidence of Professor Shaw, expert Psychiatrist accepted her evidence on that Further; there was a failure invite David's family to that MDT meeting (8 days prior to his death) but this did not contribute to David's death
Action Should Be Taken
prior point: any Policy
In opinion action should be taken to prevent future deaths and believe you have the my power to take such action.
In opinion action should be taken to prevent future deaths and believe you have the my power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.