Dudley Brown
PFD Report
Partially Responded
Ref: 2018-0211
Coroner's Concerns (AI summary)
Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling and information requirements hampered a mental health assessment.
View full coroner's concerns
(1) Following the incident on 29 December 2017 , the incident was reported to police the same The social work team leader dealing with the case was of the view that the police were the best placed to initiate emergency procedures under the Mental Health Act: (2) Mr Brown'$ care package was withdrawn on 27 December 2017 _ No arrangements were put Into place for Mr Brown's welfare to be checked in the period pending a mental health assessment: (3) The social work team leader dealing with this case was under the impression that referrals to the Approved Mental Health Practitioner Service (AMPHS) had to be made by a GP_ (4) Mr Brown'$ referral to the AMHPS and subsequent assessment was delayed due to intervening weekends (Including a 3 bank holiday weekend): (5) Mr Brown'$ assessment by the AMHPS team was delayed due to the need for information regarding the nature of his property being required by the Metropolitan Police as part of their risk assessment _
Responses
Action Planned
Hackney Council and East London Foundation Trust have formulated and are implementing a multi-agency action plan to ensure staff fluency with mental health assessment processes, review escalation pathways for service refusals, and review the AMHP referral risk assessment process; expected completion by 30th September 2018. (AI summary)
Hackney Council and East London Foundation Trust have formulated and are implementing a multi-agency action plan to ensure staff fluency with mental health assessment processes, review escalation pathways for service refusals, and review the AMHP referral risk assessment process; expected completion by 30th September 2018. (AI summary)
View full response
Dear Ms Bourke,
RE: Regulation 28 Report to Prevent Future Deaths
Mr Dudley Vincent Brown – DOB: 31/5/59 – DOD: 10/1/18 Address:
Thank you for your Regulation 28 Report issued on 27th June 2008 seeking assurance from the council and East London Foundation Trust that the circumstances surrounding the death of Mr Brown are acknowledged and addressed in order to prevent future deaths.
This is a joint response between the Council and East London Foundation Trust. We acknowledge and accept your recommendations in this case, and have worked together to address the concerns, by way of formulating and implementing a multi-agency action plan which is attached for your reference.
This focuses upon the following:
Ensuring that all staff, including managers are fluent with the processes for requesting either a general mental health assessment or a Mental Health Act assessment, which to some degree have differing referral routes, outcomes and expected response times.
A review of the current escalation pathway for service refusals by either the individual themselves or other parties on their behalf where a needs-based care package has been commissioned.
A review of the current AMHP referral risk assessment process, including the timely gathering of necessary information to assist in progressing cases, i.e. property details for Police, etc.
It is expected that this work as a whole, will be completed by the 30th September 2018, with some aspects having already been completed following the initial inquest.
As an additional assurance, the council and East London Foundation Trust have shared the circumstances and action plan with the City & Hackney Safeguarding Adults Board via its Safeguarding Adults Review Sub-Group in order to clarify if the circumstances meet the criteria for a Safeguarding Adults Review, and, if not, then to ensure that the identified learning points are shared across the partnership.
We are in agreement to the publication of this response in order to broaden learning, and we will be liaising with Mr Brown’s sister.
Please do not hesitate to contact me if further clarification is required.
RE: Regulation 28 Report to Prevent Future Deaths
Mr Dudley Vincent Brown – DOB: 31/5/59 – DOD: 10/1/18 Address:
Thank you for your Regulation 28 Report issued on 27th June 2008 seeking assurance from the council and East London Foundation Trust that the circumstances surrounding the death of Mr Brown are acknowledged and addressed in order to prevent future deaths.
This is a joint response between the Council and East London Foundation Trust. We acknowledge and accept your recommendations in this case, and have worked together to address the concerns, by way of formulating and implementing a multi-agency action plan which is attached for your reference.
This focuses upon the following:
Ensuring that all staff, including managers are fluent with the processes for requesting either a general mental health assessment or a Mental Health Act assessment, which to some degree have differing referral routes, outcomes and expected response times.
A review of the current escalation pathway for service refusals by either the individual themselves or other parties on their behalf where a needs-based care package has been commissioned.
A review of the current AMHP referral risk assessment process, including the timely gathering of necessary information to assist in progressing cases, i.e. property details for Police, etc.
It is expected that this work as a whole, will be completed by the 30th September 2018, with some aspects having already been completed following the initial inquest.
As an additional assurance, the council and East London Foundation Trust have shared the circumstances and action plan with the City & Hackney Safeguarding Adults Board via its Safeguarding Adults Review Sub-Group in order to clarify if the circumstances meet the criteria for a Safeguarding Adults Review, and, if not, then to ensure that the identified learning points are shared across the partnership.
We are in agreement to the publication of this response in order to broaden learning, and we will be liaising with Mr Brown’s sister.
Please do not hesitate to contact me if further clarification is required.
Sent To
- East London NHS Trust
- London Borough of Hackney
Response Status
Linked responses
1 of 2
56-Day Deadline
9 Oct 2018
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 17 January 2018, commenced an investigation into the death of Dudley Vincent Brown (age 58): The investigation concluded at the end of the inquest on 15 May 2018 The conclusion of the inquest was a narrative conclusion which is set out in the circumstances of the death below: The medical cause of death was: 1a: multi organ failure 1b: septic shock secondary to Klebsiella bacteraemia 1c: community acquired pneumonia 2: chronic kidney disease, Wernicke-Korsakoff syndrome _
Circumstances of the Death
Mr Brown had a number of health conditions including nephrotic syndrome, epilepsy, Wernike-Korsakov Syndrome and recurrent pulmonary embolism: He was in receipt of a care package to support hlm with personal care, meals and medication. Mr Brown'$ care package was withdrawn on 27 December 2017 after he threatened his carers with a metal bar. His Social Worker visited on 29 December 2017 and Mr Brown threatened her with a knife: The incident on 29 December 2017 was reported to police, who took no action: Mr Brown's social worker contacted his GP on 2 January 2018 and the GP referred Mr Brown for an urgent mental health assessment that evening Mr Brown'$ case was passed to the Approved Mental Health Practitioner Service (AMHPS) on the morning of 3 January 2018. A warrant was applied for under Section 135 of the Mental Health Act: This was granted on 8 January 2018. AMPHS also collated information for a Police risk assessment form, which was completed on 8 January 2018. The form was referred to the Police Mental Health Liaison Officer along with the warrant later that day: An appointment was made for the assessment to take place at Mr Brown's home at 3 pm on 10 January 2018. When Police and the AMHPS attended the property, Mr Brown was found on the floor in a state of reduced consciousness: It is unclear how long he had been there. Paramedics were called and Mr Brown was taken to the Royal London Hospital where he was found to have multi-organ failure: Mr Brown did not respond to treatment and died at the hospital on the evening of 11 January 2018.
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 YOur RESPONSE You are under a duty to respond to this report within 56 davs of the date of this report, namely by 23 August 2018./, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. day: day
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.