Julia MacPherson
PFD Report
Partially Responded
Ref: 2018-0298
Coroner's Concerns (AI summary)
Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping for off-label medication consent, and unread clinical notes, compounded by a lack of statutory consent process for informal patients.
View full coroner's concerns
(1) (t was agreed Ihat Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting t0 her care and treatment: Quetapine had been stopped due t0 concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to experence side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15*h May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concems were raised by hermother that Julia was not well enough to be_taken out_that she had no May: comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinlcian as she had no other way of contacting him, however: This review did not take place her Responsible Clinician did not see this note until the inquest: (b) Julia was not reviewed on 16*h May_ (c) A formal review of her mental capacity to consent to treatment did not take place following concerns raised by her mother on 15ih May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records_ (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy , over sedation and confusion were raised_ (4) NICE guidelines for the prescription of off licenced medicines was not followed: (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor: There is no statutory process for recording consent to medication for informal patients_
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records_ (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy , over sedation and confusion were raised_ (4) NICE guidelines for the prescription of off licenced medicines was not followed: (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor: There is no statutory process for recording consent to medication for informal patients_
Responses
Action Planned
The DHSC acknowledges the lack of a statutory process for recording consent to medication for voluntary mental health patients. They state that the Trust will implement additional safeguards, including pharmacist reviews of medications and capacity assessments, with concerns raised to the responsible clinician and clinical director. (AI summary)
The DHSC acknowledges the lack of a statutory process for recording consent to medication for voluntary mental health patients. They state that the Trust will implement additional safeguards, including pharmacist reviews of medications and capacity assessments, with concerns raised to the responsible clinician and clinical director. (AI summary)
View full response
From Jackie Doyle-Price MP Parliamentary Under Secrelary 0/ Stale for Mental Heakh and Inequalities Department Department 0f Heallh and Soclal Care of Health 39 Victoria Street London SWIH OEU Our reference: PFD [120331 Ms Sonia Hayes HM Assistant Coroner South London 0 8 MAY 2018 Coroner' s Service Floor 2, Davis House Robert Street Croydon CRO IQQ Je_Q 1a Huxt~ , Thank you for your letter of [4 February to the Secretary of State about the death of Ms Julia Jane MacPherson. Lam responding as Minister with responsibility for Mental Health and I am grateful for the extra time in which to do sO. Your report raises several areas of concern, most of which are operational matters for the Oxleas NHS Foundation Trust; I wish to provide comment in relation to the area of concern that there is no statutory process for recording consent to medication for voluntary (or informal) patients receiving mental health treatment; as there is for patients who are detained under the Mental Health Act. As you will be aware, voluntary patients should have the capacity to understand and provide consent to their treatment: Voluntary patients should be given sufficient information by their responsible clinician about proposed treatment to make an informed choice. The capacity of voluntary patients to give consent to treatment should be regularly assessed and considered by the multidisciplinary team supporting the patient Where there are concems about the patient'$ capacity, the patient' $ voluntary status should be reviewed and detention sought where clinically appropriate. Chapter 14 of the Mental Health 's Act'$ Code of Practice' discusses how this should take place: hups Iwwwsgov uklgovcmmcnupublications/code of practice-mentaL-health-act-1983
It is sadly regrettable that on this occasion a medication review and a review of MacPherson'$ capacity to consent to treatment did not take place: Learning lessons where have gone wrong is essential to ensuring the NHS provides safe, high quality care: Iam aware that the Trust has responded to you on these matters separately advising the steps it is to address the areas of concem highlighted: This includes additional safeguards for patient' $ prescribed off licence medication whereby the ward pharmacist will review the medications and ensure that all processes; including capacity assessments and efficacy of treatment; are checked and documented, bringing any concems to the attention of the responsible clinician and clinical director: understand that the Care Quality Commission (CQC) has responded to you to advise that its comprehensive inspection of the Trust conducted in 2016 did not highlight anty significant issues around the areas of concern highlighted through the Inquest into the death of Ms MacPherson: CQC will be retuming to the Trust later this year and will ensure the Trust has made the necessary improvements. this provides further assurance Thank You for bringing the circumstances of MacPherson's death to our attention. JACKIE DOYLE-PRICE Ms things taking being hope Ms 7us
It is sadly regrettable that on this occasion a medication review and a review of MacPherson'$ capacity to consent to treatment did not take place: Learning lessons where have gone wrong is essential to ensuring the NHS provides safe, high quality care: Iam aware that the Trust has responded to you on these matters separately advising the steps it is to address the areas of concem highlighted: This includes additional safeguards for patient' $ prescribed off licence medication whereby the ward pharmacist will review the medications and ensure that all processes; including capacity assessments and efficacy of treatment; are checked and documented, bringing any concems to the attention of the responsible clinician and clinical director: understand that the Care Quality Commission (CQC) has responded to you to advise that its comprehensive inspection of the Trust conducted in 2016 did not highlight anty significant issues around the areas of concern highlighted through the Inquest into the death of Ms MacPherson: CQC will be retuming to the Trust later this year and will ensure the Trust has made the necessary improvements. this provides further assurance Thank You for bringing the circumstances of MacPherson's death to our attention. JACKIE DOYLE-PRICE Ms things taking being hope Ms 7us
Noted
The CQC notes the concerns but states some relate to specific circumstances so they are unable to comment, but intends to follow through some areas of concern in more detail during an inspection later in the year. (AI summary)
The CQC notes the concerns but states some relate to specific circumstances so they are unable to comment, but intends to follow through some areas of concern in more detail during an inspection later in the year. (AI summary)
View full response
Dear Sonia Hayes Regulation 28: report to prevent future deaths following the inquest of Julia Jane MacPherson Following the inquest into the death of Julia Jane MacPherson, the Care Quality Commission (the 'CQC') received copy of the Regulation 28 report from the coroner with a letter dated the 14 February 2018. We note our legal responsibility to submit a written response t0 you, however some of the matters of concern relate to the specific circumstances of Julia MacPherson's individual care and treatment; SO we are unable as regulator to comment on this_ Since Julia Jane MacPherson's death in 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Noman Ward in March 2017 . Matters of concern: 0 8 APR very May Cor Office '2018 Rc
Timeliness of_medical reviews and assessment of_capacity: At our inspection of the acute wards, including Norman Ward in April 2016, we found that there were adequate numbers of medical staffand we do not specifically mention any difficulties with the timeliness medical reviews. We noted that patients had access to a multi-disciplinary team We also found that staff were trained and able to apply the Mental Capacity Act
2005. However, at the Mental Health Act review visit in March 2017 , it was found that two patients had been prescribed high dose anti-psychotics_ For one of the two patients, the use of high dose antipsychotics was discussed but no capacity assessment was found_ Staff not reqularly reading clinical entries_in patient records: Our report following the inspection in April 2016 does not specifically mention staff regularly reading clinical entries in patient records. It does, however; note the regular handover meetings for core staff to share information about the patients. Patient_records not_including record_of_discussions_when medication is_used outside of its licenced indication: Our report following the inspection in April 2016 said that 70 patient records were inspected The report does not specifically mention the absence of recorded discussions or decisions in individual patient records for the use of medicines outside of its licenced indication_ Prescribing not in line_with NICE quidance: The inspection in April 2016 looked at 105 medicine administration records and concluded that NICE guidance was being followed when prescribing medicines. We did record that three patients were being prescribed medicines outside of the usual levels, but do not raise any concerns about how that was being managed. Recording consent t medication for informal patients: Our report following the inspection in April 2016 does not specifically mention how consent to treatment was recorded for informal patients. It does however say that informal patients were given a leaflet explaining their rights_ We will be returning to inspect Oxleas NHS Foundation Trust later in the year: We intend to follow through some of the areas of concern in more detail_ This will be to ensure the trust has learnt from this and made the necessary improvements_
If you require any further information please do contact the Inspection Manager Judith Edwards who can be reached through our main switchboard number 03000 616161 or by email at judith edwards@cgc orguk-
Timeliness of_medical reviews and assessment of_capacity: At our inspection of the acute wards, including Norman Ward in April 2016, we found that there were adequate numbers of medical staffand we do not specifically mention any difficulties with the timeliness medical reviews. We noted that patients had access to a multi-disciplinary team We also found that staff were trained and able to apply the Mental Capacity Act
2005. However, at the Mental Health Act review visit in March 2017 , it was found that two patients had been prescribed high dose anti-psychotics_ For one of the two patients, the use of high dose antipsychotics was discussed but no capacity assessment was found_ Staff not reqularly reading clinical entries_in patient records: Our report following the inspection in April 2016 does not specifically mention staff regularly reading clinical entries in patient records. It does, however; note the regular handover meetings for core staff to share information about the patients. Patient_records not_including record_of_discussions_when medication is_used outside of its licenced indication: Our report following the inspection in April 2016 said that 70 patient records were inspected The report does not specifically mention the absence of recorded discussions or decisions in individual patient records for the use of medicines outside of its licenced indication_ Prescribing not in line_with NICE quidance: The inspection in April 2016 looked at 105 medicine administration records and concluded that NICE guidance was being followed when prescribing medicines. We did record that three patients were being prescribed medicines outside of the usual levels, but do not raise any concerns about how that was being managed. Recording consent t medication for informal patients: Our report following the inspection in April 2016 does not specifically mention how consent to treatment was recorded for informal patients. It does however say that informal patients were given a leaflet explaining their rights_ We will be returning to inspect Oxleas NHS Foundation Trust later in the year: We intend to follow through some of the areas of concern in more detail_ This will be to ensure the trust has learnt from this and made the necessary improvements_
If you require any further information please do contact the Inspection Manager Judith Edwards who can be reached through our main switchboard number 03000 616161 or by email at judith edwards@cgc orguk-
Sent To
- Care Quality Commission
- Department for Health
- Oxleas NHS Trust
Response Status
Linked responses
2 of 3
56-Day Deadline
16 Mar 2019
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 27th September 2016 the Senior Coroner commenced an investigation into the death of Julia Jane MacPherson age 54. The investigation concluded at the end of the inquest on 24" November 2017. The conclusion of the inquest was the medical cause of death being Ia Upper Airway Obstruction 1b underlying swallowing difficulties Ic Extrapyramidal symptoms of medication muscle rigidity and tachycardia.
Circumstances of the Death
An informal patient at Oxleas NHS Foundation Trust with a history of personality disorder; anxiety and self-harm treated as an informal patient with medication that caused extra pyramidal symptoms_ She suffered swallowing dificulties and collapsed in the community with food bolus and vomitus in the throat: London Ambulance Service attended but PEA persisted despite advanced CPR and reversal of potential causes on 18th Confirmed life extinct at 12.15.
Action Should Be Taken
In my opinion, action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Recording Clinical Discussions
Hyponatraemia Inquiry
No person-centred care
Inaccurate and inaccessible patient records
CDI patient information
Vale of Leven Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Provide evidence-based patient information in a comprehensible summary format
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Regularly update and pilot patient information materials with active patient involvement
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
NHS Modernisation Agency to prioritise patient information quality and establish accreditation system
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Develop kitemarking system for reliable internet health information guidance for public
Bristol Heart Inquiry
No person-centred care
Inaccurate and inaccessible patient records
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.