Layla Dobson
PFD Report
All Responded
Ref: 2019-0425
All 1 response received
· Deadline: 10 Feb 2020
Coroner's Concerns (AI summary)
Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to inadequate scrutiny.
View full coroner's concerns
In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory to report to you The matter of concern is as follows_ Although the PDCN considered Layla's referral, notwithstanding it does not take self-referrals to its care coordination services, the evidence provided at the inquest indicated that there was no formalised or tangible process to or otherwise inform practitioners as to which route of support would be appropriate for an individual. Whilst the approach to the CMHT was decided upon and actioned, my view upon the evidence was that the area on the form relating to current self-harm/suicide is not further flagged or referenced to those taking relevant decisions and this could strengthen the scrutiny of information when deciding upon which service may be contacted. Whilst the evidence at the inquest was clear that Layla was under the care of her GP who later assessed her mental health/risk on 8t March 2018, am of the view that the process whereby an individual seeks to requestlaccess mental services could be strengthened by guidance or referencing such that each pathway of support is systematically considered_ am under a duty to report this matter upon consideration of the evidence.
Responses
Action Taken
Leeds and York NHS Trust has created guidance for staff on assessing risk in referrals, ensuring consideration of self-harm/suicide risk. They will update the referral form and information leaflet, and implement a standard referral receipt letter providing details of relevant crisis support services. (AI summary)
Leeds and York NHS Trust has created guidance for staff on assessing risk in referrals, ensuring consideration of self-harm/suicide risk. They will update the referral form and information leaflet, and implement a standard referral receipt letter providing details of relevant crisis support services. (AI summary)
View full response
Dear Mr McLoughlin, RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Layla Stephanie DOBSON, (deceased) Thank you for the correspondence regarding the outcome of the inquest which was concluded on Tuesday 8 October 2019, touching upon the death of Ms Layla Stephanie Dobson: would firstly like to take this opportunity to express my sincere condolences to Layla's family and friends at the tragic loss of Layla: Following the Regulation 28 Report to Prevent Future Deaths issued on the 16 December 2019 to Leeds and York Partnership NHS Foundation Trust (LYPFT), please find below the details of the response to address the concerns raised_ The Matters of Concern are in bold text with the Trust's response following: Although the PDCN considered Layla's referral, notwithstanding it does not take referrals to its care coordination services, the evidence provided at the inquest indicated that there was no formalised or tangible process to guide or otherwise inform practitioners as to which route of support would be appropriate for an individual: Whilst the approach to the CMHT was decided upon and actioned; my view upon the evidence was that the area on the form relating to current self-harmlsuicide is not further flagged or referenced to those taking relevant decisions and this could strengthen the scrutiny of information when deciding upon which service may be contacted: integrity simplicity caring
Way self-
Whilst the evidence at the inquest was clear that Layla was under the care of her GP who later assessed her mental healthlrisk on O8th March 2018, am of the view that the process whereby an individual seeks to requestlaccess mental services could be strengthened by guidance or referencing such that each pathway of support is systematically considered: The Personality Disorder Clinical Network service has carefully considered the matters of concerns outlined and agreed an action plan (appendix 1) at the service Clinical Governance forum held on the 30th January 2020. Firstly the service is developing guidance to further inform the decision making process with regards to referral to relevant crisis support services: The guidance will include for example: Ascertaining whether an imminent risk of suicide is identified in the referral information. Whether mental health service support is already currently available for the service user: Whether the referral is a 'self-referral' _ This guidance will routinely be considered at the referral meeting stage and is intended to support decisions taken by the membership of the referral meeting as to a proportionate response to the risk information available at that in the referral process: It will include reference to recommended 'steps' to consider should a referral be identified as indicating an imminent risk of suicide and where support from appropriate mental health services is not already in place_ Reference to this guidance will then be routinely made in the clinical case record pertaining to each referral_ The service is also aware that there may be instances where the referral not be considered by the referral team for up to 7 days or where direct contact with the service user was considered the most appropriate course of action and 'did not attend' As such the service referral form and information leaflet (available via the LYPFT website) will be updated to provide details of relevant crisis support services in Leeds: The service will additionally change its process for responding to self-referrals by developing standard referral receipt letter which will automatically be emailed andlor posted to service users outlining relevant crisis support services: This measure is intended to additionally ensure that service users referred to the service will always be made aware of the relevant services in the who may be able to provide a crisis service level of response, pending the referral outcome hope that this response provides assurance of improvement, consistent with the concerns highlighted in the Regulation 28. We would be pleased to provide any further information or clarification required_
Way self-
Whilst the evidence at the inquest was clear that Layla was under the care of her GP who later assessed her mental healthlrisk on O8th March 2018, am of the view that the process whereby an individual seeks to requestlaccess mental services could be strengthened by guidance or referencing such that each pathway of support is systematically considered: The Personality Disorder Clinical Network service has carefully considered the matters of concerns outlined and agreed an action plan (appendix 1) at the service Clinical Governance forum held on the 30th January 2020. Firstly the service is developing guidance to further inform the decision making process with regards to referral to relevant crisis support services: The guidance will include for example: Ascertaining whether an imminent risk of suicide is identified in the referral information. Whether mental health service support is already currently available for the service user: Whether the referral is a 'self-referral' _ This guidance will routinely be considered at the referral meeting stage and is intended to support decisions taken by the membership of the referral meeting as to a proportionate response to the risk information available at that in the referral process: It will include reference to recommended 'steps' to consider should a referral be identified as indicating an imminent risk of suicide and where support from appropriate mental health services is not already in place_ Reference to this guidance will then be routinely made in the clinical case record pertaining to each referral_ The service is also aware that there may be instances where the referral not be considered by the referral team for up to 7 days or where direct contact with the service user was considered the most appropriate course of action and 'did not attend' As such the service referral form and information leaflet (available via the LYPFT website) will be updated to provide details of relevant crisis support services in Leeds: The service will additionally change its process for responding to self-referrals by developing standard referral receipt letter which will automatically be emailed andlor posted to service users outlining relevant crisis support services: This measure is intended to additionally ensure that service users referred to the service will always be made aware of the relevant services in the who may be able to provide a crisis service level of response, pending the referral outcome hope that this response provides assurance of improvement, consistent with the concerns highlighted in the Regulation 28. We would be pleased to provide any further information or clarification required_
Sent To
- Leeds and York Partnership NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
10 Feb 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 18th March 2019 an investigation was commenced into the death of Miss Layla Stephanie Dobson; aged 23_ investigation concluded at the end of the inquest on 8th October 2019. The medical cause of death established at the inquest was that Miss Dobson's died by way of hanging_ A conclusion of suicide was recorded.
Circumstances of the Death
On 11th March 2019 Layla Stephanie Dobson was found deceased at her home address in Headingley Avenue, Leeds. Layla was a student who suffered with mental health issues and had been engaged with mental health services over the course of a number of years in her home city of Hull, prior to moving to Leeds_ On &th February 2019 Layla completed a self-referral form to the Leeds Personality Disorder Clinical Network ("PDCN") in which she set out a background including self-harm and suicidal ideation in the context of a recent relationship breakdown. She expressed a wish to be supported by the specialist support of NHS mental health services_ On the section of the form headed 'Self-harm/suicide (e.g: cutting, misuse of medication/overdosing and eating difficulties)' Layla indicated recorded current matters of 'cutting; recent attempt of hanging, banging head into wall, hair pulling, drugs + alcohol, restrictive eating'_ Although aspects of the Trust mental health services do accept self-referrals, the PDCN does not do so to its care CO-ordination services. Nevertheless, Layla's referral was discussed at a meeting on 25th February 2019 and it was decided that the Clinical Team Manager, Ellen Scroop would contact the relevant Community Mental Health Team to discuss whether an assessment of Layla's needs could be offered. Miss Scroop gave evidence at the inquest and question was raised as t0 any consideration f a referral to appropriate Crisis Team support; in view of matters disclosed by Layla, and specifically to current self-harm/suicide on the referral The records show that contact with the CMHT was followed up in late March 2019_ and The Miss the the form .
Evidence was also heard that Layla had appointments with her GP on 1st February, 8th February, 22nd February and 8th March 2018. At the last appointment her mental health and ievel of risk was explored and Layla denied any intention of suicide or self-tarm,
Evidence was also heard that Layla had appointments with her GP on 1st February, 8th February, 22nd February and 8th March 2018. At the last appointment her mental health and ievel of risk was explored and Layla denied any intention of suicide or self-tarm,
Action Should Be Taken
in my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.