Heather Carey
PFD Report
All Responded
Ref: 2019-0046
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
All 2 responses received
· Deadline: 19 Jul 2019
Coroner's Concerns (AI summary)
Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to physical life-threatening illnesses, causing distress and increasing suicide risk.
View full coroner's concerns
The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin At the time of Heather's admission to TGH there was no psychotherapy available to as an in-patient because there were insufficient funds available t0 provide the same: was told that had been addressed by further funding being made available At the time of Heather's assessment on 22.11 staffing levels were reduced, through iliness and a vacancy; and there was only one psychotherapist available That was the reason given for the 24 weeks wait; At the inquest heard evidence that the target waiting list was 18 weeks. Further , that by the time of the inquest that target time was met: A target waiting time of 18 weeks, was told, was comparable to 'cancer waiting times" However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral: Heather was already in receipt of consultant led care. Her need was urgent: Thus such a comparator on waiting times to justify a 18 weeks wait for psychotherapy is not an appropriate measure. By letter dated 3" January 2019 Pennine Care responded to my concerns about the waiting list as follows_ "The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life , a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the helpltreatment she was seeking on voluntary admission some 4 months previously. A target waiting list of 18 weeks is far too long but was told that this was funding issue. Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental iII-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for treatment:
Responses
Action Taken
The CCG has invested £600,000 to improve staffing on inpatient mental health wards. The service's waiting times have improved due to internal actions, with the current waiting time for Cognitive Analytical Therapy at 13 weeks. (AI summary)
The CCG has invested £600,000 to improve staffing on inpatient mental health wards. The service's waiting times have improved due to internal actions, with the current waiting time for Cognitive Analytical Therapy at 13 weeks. (AI summary)
View full response
Dear Mr Bridgman,
Re: Heather Louise CAREY - Regulation 28 - Prevention of Future Deaths
Further to your letter, dated 12 February 2019 and my acknowledgement, regarding the tragic death of Heather Louise Carey, please find our response outlined below.
Clearly the untimely death of any person is distressing for the family and any others affected by their death and loss, and all the more so if there is any belief that but for the actions of any organisation it could have been avoided.
I would like to record my sincere condolences to the Heather Louise Carey’s family for their loss and I hope through this process they can obtain some closure.
The Inquest identified a number of issues which likely contributed to Ms Carey’s decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin.
At the time of Ms Carey’s admission to TGH there was no psychotherapy available to her as an inpatient because there were insufficient funds available to provide the same. I understand you were informed that this issue was being addressed by further funding being made available.
At the time of Ms Carey’s assessment on the 22 November 2018, staffing levels were reduced through illness and vacancy and only one psychotherapist was available. That was the reason given for the 24 week wait in excess of the target waiting list of 18 weeks, which you were advised, was the maximum waiting time for non-urgent consultant led treatment from the point of referral. However, Ms Carey was already in receipt of consultant led care and her need was assessed as urgent and therefore in your opinion such a comparator was inappropriate.
Accordingly, the concern you raise is that unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill health, comparable to physical life threatening illnesses, not simply a redistribution of existing resources, more patients with mental health issues will end their lives whilst on a waiting list for treatment.
Thank you for bringing this significant issue to my attention, I share your concerns.
STRICTLY PRIVATE AND CONFIDENTIAL Mr Bridgman HM Assistant Coroner Coroner’s Court 1 Mount Tabor Street STOCKPORT SK1 3AG
CHIEF EXECUTIVE & ACCOUNTABLE OFFICER
Chief Executive, Tameside MBC and Accountable Officer, Tameside & Glossop CCG
Tameside One, Market Place, Ashton under Lyne, OL6 6BH
Date 8 April 2019
2 | P a g e
The Responsible Senior Officer for this work is Jessica Williams, Interim Director of Commissioning.
I’m advised that the following action has been taken owing to concerns raised through this case and others, the CCG is taking forward a number of actions and in particular relating to the two concerns you raise
1) WAITING TIMES FOR SECONDARY CARE PSYCHOLOGICAL THERAPY
a. Psychological Therapies Review - commenced in October 2018 this review focuses on access and quality of psychological therapy services for people with more complex needs including those under the care of the Community Mental Health Teams. The review identified that while NICE concordat therapy services are being provided waiting times for treatment are too long in some services.
The reviewing team are using this information alongside an exploration of alternative models of care to develop a new model of psychological therapy for people with complex mental health needs in Tameside and Glossop. This review will conclude by the 31 of July
2019.
b. Improving access to psychological therapy – the Tameside and Glossop Strategic Commissioning Board has committed additional funding to increase access to psychological therapies. An additional £271,000 agreed in 2018/19 will be increased by an additional £673,000 per annum by 2021 to meet a range of pressures.
c. Improving monitoring – the CCG is working with the Trust to develop a new Performance and Quality Outcome Framework for the 2019/20 Pennine Care contract. This will ensure that activity, waiting times and outcomes for every service are routinely reported and robustly monitored.
d. Current performance in Secondary Care Psychological Therapies – the CCG is advised that due to actions taken internally the current waiting times for the service have improved, with a current waiting time for Cognitive Analytical Therapy of 13 weeks.
e. Support for people waiting for therapy – we have asked the Secondary Care Psychological Therapy Service to ensure that that when people are advised about the waiting times that they are supported to work with their care coordinator for stabilisation, containment and pre therapy work in preparation for therapy to ensure that they do not suffer the distress and despair that Ms Carey’s family state that Ms Carey experienced and evidenced by her tragic death.
2) NO PSYCHO-THERAPY AVAILABLE TO MS CAREY DURING HER INPATIENT ADMISSION
The CCG has invested £600,000 recurrently to improve staffing on the inpatient mental health wards at Tameside Hospital with a focus on improving safety, patient experience and outcomes. The Trust has invested this funding in improving the skill mix of the teams, including additional clinical psychology and occupational therapy, as well as nursing and admin. The CCG is formally monitoring the impact of this investment through regular Safer Staffing Reports presented to the Pennine Care Quality Group. Reports from staff on the Tameside wards and the latest CQC report indicate that this is having a positive impact.
We shall keep this issue under review as part of the quality monitoring reported to the Strategic Commissioning Board, whose meetings are held in public.
3 | P a g e
I hope this brings some reassurance that we are working to ensure another tragic loss of live doesn’t occur in similar circumstances.
Please contact me if you require any further information or if I can assist further in any way.
Re: Heather Louise CAREY - Regulation 28 - Prevention of Future Deaths
Further to your letter, dated 12 February 2019 and my acknowledgement, regarding the tragic death of Heather Louise Carey, please find our response outlined below.
Clearly the untimely death of any person is distressing for the family and any others affected by their death and loss, and all the more so if there is any belief that but for the actions of any organisation it could have been avoided.
I would like to record my sincere condolences to the Heather Louise Carey’s family for their loss and I hope through this process they can obtain some closure.
The Inquest identified a number of issues which likely contributed to Ms Carey’s decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin.
At the time of Ms Carey’s admission to TGH there was no psychotherapy available to her as an inpatient because there were insufficient funds available to provide the same. I understand you were informed that this issue was being addressed by further funding being made available.
At the time of Ms Carey’s assessment on the 22 November 2018, staffing levels were reduced through illness and vacancy and only one psychotherapist was available. That was the reason given for the 24 week wait in excess of the target waiting list of 18 weeks, which you were advised, was the maximum waiting time for non-urgent consultant led treatment from the point of referral. However, Ms Carey was already in receipt of consultant led care and her need was assessed as urgent and therefore in your opinion such a comparator was inappropriate.
Accordingly, the concern you raise is that unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill health, comparable to physical life threatening illnesses, not simply a redistribution of existing resources, more patients with mental health issues will end their lives whilst on a waiting list for treatment.
Thank you for bringing this significant issue to my attention, I share your concerns.
STRICTLY PRIVATE AND CONFIDENTIAL Mr Bridgman HM Assistant Coroner Coroner’s Court 1 Mount Tabor Street STOCKPORT SK1 3AG
CHIEF EXECUTIVE & ACCOUNTABLE OFFICER
Chief Executive, Tameside MBC and Accountable Officer, Tameside & Glossop CCG
Tameside One, Market Place, Ashton under Lyne, OL6 6BH
Date 8 April 2019
2 | P a g e
The Responsible Senior Officer for this work is Jessica Williams, Interim Director of Commissioning.
I’m advised that the following action has been taken owing to concerns raised through this case and others, the CCG is taking forward a number of actions and in particular relating to the two concerns you raise
1) WAITING TIMES FOR SECONDARY CARE PSYCHOLOGICAL THERAPY
a. Psychological Therapies Review - commenced in October 2018 this review focuses on access and quality of psychological therapy services for people with more complex needs including those under the care of the Community Mental Health Teams. The review identified that while NICE concordat therapy services are being provided waiting times for treatment are too long in some services.
The reviewing team are using this information alongside an exploration of alternative models of care to develop a new model of psychological therapy for people with complex mental health needs in Tameside and Glossop. This review will conclude by the 31 of July
2019.
b. Improving access to psychological therapy – the Tameside and Glossop Strategic Commissioning Board has committed additional funding to increase access to psychological therapies. An additional £271,000 agreed in 2018/19 will be increased by an additional £673,000 per annum by 2021 to meet a range of pressures.
c. Improving monitoring – the CCG is working with the Trust to develop a new Performance and Quality Outcome Framework for the 2019/20 Pennine Care contract. This will ensure that activity, waiting times and outcomes for every service are routinely reported and robustly monitored.
d. Current performance in Secondary Care Psychological Therapies – the CCG is advised that due to actions taken internally the current waiting times for the service have improved, with a current waiting time for Cognitive Analytical Therapy of 13 weeks.
e. Support for people waiting for therapy – we have asked the Secondary Care Psychological Therapy Service to ensure that that when people are advised about the waiting times that they are supported to work with their care coordinator for stabilisation, containment and pre therapy work in preparation for therapy to ensure that they do not suffer the distress and despair that Ms Carey’s family state that Ms Carey experienced and evidenced by her tragic death.
2) NO PSYCHO-THERAPY AVAILABLE TO MS CAREY DURING HER INPATIENT ADMISSION
The CCG has invested £600,000 recurrently to improve staffing on the inpatient mental health wards at Tameside Hospital with a focus on improving safety, patient experience and outcomes. The Trust has invested this funding in improving the skill mix of the teams, including additional clinical psychology and occupational therapy, as well as nursing and admin. The CCG is formally monitoring the impact of this investment through regular Safer Staffing Reports presented to the Pennine Care Quality Group. Reports from staff on the Tameside wards and the latest CQC report indicate that this is having a positive impact.
We shall keep this issue under review as part of the quality monitoring reported to the Strategic Commissioning Board, whose meetings are held in public.
3 | P a g e
I hope this brings some reassurance that we are working to ensure another tragic loss of live doesn’t occur in similar circumstances.
Please contact me if you require any further information or if I can assist further in any way.
Action Planned
NHS England will test four-week waiting times to appropriate care and is expected to publish a Community Mental Health Framework to support local areas in the transformation of community mental health services. NHS England is also investing to improve the therapeutic skill mix of staff. (AI summary)
NHS England will test four-week waiting times to appropriate care and is expected to publish a Community Mental Health Framework to support local areas in the transformation of community mental health services. NHS England is also investing to improve the therapeutic skill mix of staff. (AI summary)
View full response
• From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health, Department Inequalities and Suicide Prevention of Health & 39 Victoria Street Social Care London SW1H0EU 020 7210 4850
Mr Andrew Bridgman HM Assistant Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SKI 3AG <g"/ft_ May2019 Thank you for your correspondence of 12 February about the death ofMiss Heather Louise Carey. I am grateful for the additional time in which to reply. Firstly, I would like to say how very sorry I was to read ofthe circumstances ofMiss Carey's death. I appreciate her loss must be extremely distressing for her family and loved ones and I offer my sincerest condolences. Your report offers significant learning to the local NHS and I expect firm action to be taken by both the local commissioner and provider ofservices to respond to the concerns raised and the failings identified. I am aware that the Tameside and Glossop Clinical Commissioning Group (CCG) has responded to you with information on the action it is taking locally to improve access to secondary care psychological therapy. This includes the development ofa new model ofpsychological therapy for people with complex mental health needs, as well as increased investment to support improved access to psychological therapies. In addition, the CCG is working with the Pennine Care NHS Foundation Trust to agree a Performance and Outcome Framework for 2019-20 to ensure activity, waiting times and outcomes are reported and monitored. I should make clear that the 18-week waiting time of which you were advised at inquest relates to the Improving Access to Psychological Therapies (IAPT) programme. The evidence-based psychological therapies provided through IAPT are designed to offer intervention for adults with common mental health problems, such
as depression and anxiety. I would therefore like to explain the action we are taking at a national level to improve access to treatment for those with severe mental illness. The Five Year Forward View for Mental Health 1, published in 2016, recommended investment to increase access to psychological therapies for people with severe mental illness, namely psychosis, bipolar disorder and personality disorder. This ambition is reiterated and built upon in the NHS Long Term Plan2, published in January 2019. The Improving Access to Psychological Therapies - Severe Mental Illness (IAPT- SMI) sites have demonstrated the positive impact ofaccess to NICE-recommended psychological interventions on experience, outcomes and reduced healthcare utilisation. NHS England and Health Education England are working to build on the IAPT-SMI programme and 'scale-up' so that a greater number ofpeople have access to psychological therapy as a core component ofthe adult mental health services offer. This year, funding is being made available to test new models ofcommunity mental health care. This includes testing ways to improve timely access to courses of psychological therapies for people with psychosis, bipolar disorder and personality disorder. In addition, NHS England will test four-week waiting times to appropriate care, to help build our understanding ofhow best to introduce ambitious but achievable improvements to access, quality ofcare and outcomes. NHS England is expected to publish shortly a Community Mental Health Framework to support local areas in the transformation ofcommunity mental health services. This will include a focus on ensuring NICE-recommended psychological therapies are offered (where clinically appropriate) in the community. Finally, the NHS Long Term Plan, in accordance with the recommendations in the Independent Review ofthe Mental Health Act3, commits to the creation of therapeutic inpatient environments which provide the best opportunity for recovery. To ensure the provision ofpurposeful, patient-orientated and recovery-focused inpatient care, NHS England is investing to improve the therapeutic skill mix ofstaff. For example, allied health professionals and psychological professions such as occupational therapists, psychologists and physiotherapists, as well as peer support workers will enable therapeutic interventions to be delivered more flexibly across ' https:l/www.england.nhs.uk/wp-content/uploads/2O16/02/Mental-Health-Taskforce-FYFV-final.pdf 2 hmis:llwww.longtermplan.nhs.uk/ 3 https:l/www.gov.uk/government/groups/independent-review-of-the-mental-health-act
inpatient and community settings, facilitating timely, clinically appropriate discharge, as well as continuity of care pre- and post-discharge. I hope this information is helpful and provides assurance that measures are being taken to improve access to psychological therapies for those with severe mental ill health. I am grateful to you for bringing these matters to my attention. JACKIE DOYLE-PRICE
Mr Andrew Bridgman HM Assistant Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SKI 3AG <g"/ft_ May2019 Thank you for your correspondence of 12 February about the death ofMiss Heather Louise Carey. I am grateful for the additional time in which to reply. Firstly, I would like to say how very sorry I was to read ofthe circumstances ofMiss Carey's death. I appreciate her loss must be extremely distressing for her family and loved ones and I offer my sincerest condolences. Your report offers significant learning to the local NHS and I expect firm action to be taken by both the local commissioner and provider ofservices to respond to the concerns raised and the failings identified. I am aware that the Tameside and Glossop Clinical Commissioning Group (CCG) has responded to you with information on the action it is taking locally to improve access to secondary care psychological therapy. This includes the development ofa new model ofpsychological therapy for people with complex mental health needs, as well as increased investment to support improved access to psychological therapies. In addition, the CCG is working with the Pennine Care NHS Foundation Trust to agree a Performance and Outcome Framework for 2019-20 to ensure activity, waiting times and outcomes are reported and monitored. I should make clear that the 18-week waiting time of which you were advised at inquest relates to the Improving Access to Psychological Therapies (IAPT) programme. The evidence-based psychological therapies provided through IAPT are designed to offer intervention for adults with common mental health problems, such
as depression and anxiety. I would therefore like to explain the action we are taking at a national level to improve access to treatment for those with severe mental illness. The Five Year Forward View for Mental Health 1, published in 2016, recommended investment to increase access to psychological therapies for people with severe mental illness, namely psychosis, bipolar disorder and personality disorder. This ambition is reiterated and built upon in the NHS Long Term Plan2, published in January 2019. The Improving Access to Psychological Therapies - Severe Mental Illness (IAPT- SMI) sites have demonstrated the positive impact ofaccess to NICE-recommended psychological interventions on experience, outcomes and reduced healthcare utilisation. NHS England and Health Education England are working to build on the IAPT-SMI programme and 'scale-up' so that a greater number ofpeople have access to psychological therapy as a core component ofthe adult mental health services offer. This year, funding is being made available to test new models ofcommunity mental health care. This includes testing ways to improve timely access to courses of psychological therapies for people with psychosis, bipolar disorder and personality disorder. In addition, NHS England will test four-week waiting times to appropriate care, to help build our understanding ofhow best to introduce ambitious but achievable improvements to access, quality ofcare and outcomes. NHS England is expected to publish shortly a Community Mental Health Framework to support local areas in the transformation ofcommunity mental health services. This will include a focus on ensuring NICE-recommended psychological therapies are offered (where clinically appropriate) in the community. Finally, the NHS Long Term Plan, in accordance with the recommendations in the Independent Review ofthe Mental Health Act3, commits to the creation of therapeutic inpatient environments which provide the best opportunity for recovery. To ensure the provision ofpurposeful, patient-orientated and recovery-focused inpatient care, NHS England is investing to improve the therapeutic skill mix ofstaff. For example, allied health professionals and psychological professions such as occupational therapists, psychologists and physiotherapists, as well as peer support workers will enable therapeutic interventions to be delivered more flexibly across ' https:l/www.england.nhs.uk/wp-content/uploads/2O16/02/Mental-Health-Taskforce-FYFV-final.pdf 2 hmis:llwww.longtermplan.nhs.uk/ 3 https:l/www.gov.uk/government/groups/independent-review-of-the-mental-health-act
inpatient and community settings, facilitating timely, clinically appropriate discharge, as well as continuity of care pre- and post-discharge. I hope this information is helpful and provides assurance that measures are being taken to improve access to psychological therapies for those with severe mental ill health. I am grateful to you for bringing these matters to my attention. JACKIE DOYLE-PRICE
Sent To
- Department of Health and Social Care
- NHS Tameside and Glossop Clinical Commissioning Group
Response Status
Linked responses
2 of 2
56-Day Deadline
19 Jul 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
Inquest touching the death of Heather Louise Carey: Opened 8h January 2018 Concluded 1* November 2018. Medical Cause of Death Ia Hanging Conclusion Suicide: Heather Carey took her own life when she had been in the care of NHS Mental Health Services for 6Y2 months; she had recently been placed on waiting list of some 24 weeks for Cognitive Analytical Therapy Although Heather Carey was known to be depressed, compounded by the lack of medication prescribed to lessen that depression, and at high risk of suicide from the time she had been discharged hospital (following a serious overdose 6 weeks prior to her death) there was failure to take adequate and appropriate action to avert or reduce that risk and, just 2 before her death; inappropriate steps were taken which may have increased that risk:
Circumstances of the Death
On 04.07.17 Heather Carey was admitted as voluntary patient to the Mental Health Unit, Tameside General Hospital, seeking treatment for her enduring mental illness diagnosed as bi-polar disorder. Heather was detained under section 2 of the Mental Health Act on 13.07.17 On 24.08.17 Heather Carey was discharged. Her discharge medication was quetiapine, intended to lessen the depth of her depressive mood swings: Heather was expecting referral to have been made that for psychotherapy assessment: On discharge Heather Carey' s Out Patient Clinic Appointment was to be within 2-3 weeks (14.09.2017) but she was given a appointment on 04.10.17. Following this appointment Heather was referred for psychotherapy screeninglassessment: That is the usual practice King from days day
On 02.11.17 Heather was admitted t0 Tameside General Hospital having taken an overdose of paracetamol. Quetiapine was stopped pending liver and renal function tests_ Heather was discharged from Tameside General Hospital on 10.11.17. From discharge Heather Carey was a Red Zone high priority patient: Heather attended for her psychotherapy assessment on 22.11.17 The psychotherapist was not aware of the recent overdose. Heather was told that she was ready t0 consider Cognitive Analytical Therapy but that there was 24-week waiting list: The psychotherapist sensed a disappointment. The evidence showed that for Heather seemed Iike all hope had gone. Thereafter Heather'$ disengagement from the mental health team worsened. On the morning of 20.12.17 Heather Carey hanged herself at her home
On 02.11.17 Heather was admitted t0 Tameside General Hospital having taken an overdose of paracetamol. Quetiapine was stopped pending liver and renal function tests_ Heather was discharged from Tameside General Hospital on 10.11.17. From discharge Heather Carey was a Red Zone high priority patient: Heather attended for her psychotherapy assessment on 22.11.17 The psychotherapist was not aware of the recent overdose. Heather was told that she was ready t0 consider Cognitive Analytical Therapy but that there was 24-week waiting list: The psychotherapist sensed a disappointment. The evidence showed that for Heather seemed Iike all hope had gone. Thereafter Heather'$ disengagement from the mental health team worsened. On the morning of 20.12.17 Heather Carey hanged herself at her home
Action Should Be Taken
her being long
In my opinion action should be taken t0 prevent future deaths and believe you have the power t0 take such action.
In my opinion action should be taken t0 prevent future deaths and believe you have the power t0 take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.