UK Inquiry Tracker

Mohammed Hussain

PFD Report All Responded Ref: 2019-0122

Date of Report 13 March 2019

Coroner Emma Whitting

Coroner Area Bedfordshire & Luton

Response Deadline est. 9 September 2019

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 9 Sep 2019

Coroner's Concerns (AI summary)

Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care providers. Despite further training, staff lacked insight into their actions.

View full coroner's concerns

May life , Iow;

(1) The Trust had carried out Serious Incident Investigation (SII) into the circumstances of the Mr Hussain's death which was critical of both the mental health assessments of Mr Hussain carried out by staff on 30 April and May 2018. This meant that individual staff members had misunderstood or misapplied their risk assessment training: (2) was informed by the Trust that further risk assessment training was carried out by the Trust following Mr Hussain's death and yet, at the Inquest; both members of staff (although, one has now moved to another Trust) showed Iittle insight into their actions despite the SII 's findings and the further training (3) It was also apparent at the Inquest that important information required for the risk assessment process had not necessarily been passed andlor sufficiently highlighted in communications both between individual Trust staff members and with other care providers

Responses

East London NHS Trust NHS / Health Body

13 Mar 2019

Action Taken
Further training on risk assessment and suicide prevention is being delivered to staff in Bedfordshire crisis services. A new Clinical Director for Crisis Pathway and Liaison has been appointed to review the crisis pathway, and the Trust is working with external experts to develop a new risk assessment tool for wider rollout; suicide prevention training is also being reviewed and refreshed. (AI summary)

View full response

Dear Madam Inquest touching upon the death of Mohammed Hussain This is a formal response to your Regulations 28 Report dated 13th March 2019 in which you set out your concerns relating to the care Mr Hussain received from East London NHS Foundation Trust. Your concerns related to the assessment of risk by staff in our Bedford crisis services on both 30 April and 1 May 2018. As you have noted this was identified in the Trust's Serious Incident Review Report am aware that you heard evidence during the course of the Inquest that the Trust has mandatory training in Clinical Risk Assessment in place and that as a result of the concerns highlighted in the Serious Incident Review additional risk assessment training had been into place and would continue to be delivered on an ongoing basis However, having heard the evidence of staff, you were concerned that they had potentially misunderstood or misapplied both the mandatory and additional risk assessment training: The importance of good quality, appropriate risk assessment is a skill for all our clinical staff and the Trust is looking at several ways to support staff with this. Within the crisis services in Bedfordshire further training has now been organised and is currently being delivered to staff specifically looking at assessment of risk and suicide prevention. Chair Chief Executive: Dr Navina Evans put key

In addition we have recently appointed to a new role of Clinical Director for Crisis Pathway and Liaison and the postholder will be reviewing the whole crisis pathway to identify and implement improvements. Given the importance of this issue am also looking at this on a Trust wide basis and have been working with external experts with a view to developing a new risk assessment tool to roll out across the Trust. acknowledge that this work may take some time to refine and implement In the meantime a Suicide Prevention Awareness has been organised for July and our suicide prevention training is currently being reviewed and refreshed for implementation across our services, that the information above reassures you that the Trust has taken your concerns seriously and that the action taken has adequately addressed those concerns_ If you do require any further information please do not hesitate to contact me_

Part of a Series

2 separate reports were issued from this inquest, each sent to different organisations.

2023-0241
Sent to: Birmingham and Solihull Mental Health Foundation TrustDepartment of Health and Social Care

All responded

This report (2019-0122) is shown above.

Sent To

East London NHS Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 9 Sep 2019

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 15 2018 the Acting Senior Coroner for Bedfordshire & Luton commenced an investigation was into the death of Mr Mohammed Hussain, aged 30. The investigation concluded at the end of the Inquest held by me on 26 February 2019 and on 7 March 2019 my determinations and conclusion were delivered. The medical cause of death was found to be: 1a Carbon Monoxide Toxicity and Extensive Burns The Conclusion of the Inquest was a Narrative Conclusion: The Deceased took his own intending to do so, but whilst suffering from mental distress

Circumstances of the Death

The Deceased suffered a deterioration in his mental health from November 2017. On 21 December 2017 , he was admitted to the Luton Dunstable hospital following an overdose and was assessed by psychiatric services who referred him for GP review. On 28 April 2018, he took a further overdose and, on 30 April 2018, was assessed by his GP as being at high risk of suicide and was re-referred to psychiatric services. Although he was still at high risk, psychiatric services initially assessed him to be at medium risk and he was discharged for a community assessment at home the following day when his risk level was further reduced to apart from counselling services and medication, he was not offered any further psychiatric support. As his condition continued to deteriorate , alternative medical management may have altered subsequent events. On 12 March 2018, he drove himself to Eldon Rd, Luton, where he parked and, shortly before 18.00 hours, having soaked the interior of the car with fuel, he set fire to himself whilst sitting in the rear passenger seat: His death was confirmed by police who attended the scene at 19.00 hours_

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_