UK Inquiry Tracker

Karen Edgar

PFD Report Partially Responded Ref: 2018-0106

Date of Report 16 April 2018

Coroner David Roberts

Coroner Area Cumbria

Response Deadline est. 12 August 2018

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.

View full coroner's concerns

In the circumstances it is my statutory to report to you: (1) The provision of mental health services for children and young people in Cumbria is underfunded: (2) There are long delays in getting treatment: (3) Failure to provide for these young people means they risk entering adulthood with unresolved mental health issues (4) Lives are lost and damaged; including the effect on families as a whole: (S) The financial cost to the state of such deaths is huge; 4 paramedics attended as did an out of hours doctor; at least 11 police staff; hospital staff; A&E consultant; Local Safeguarding processes; costs of inquests and Trust' $ legal representation etc all of which would be better spent on prevention: (6) It is likely that any of these problems are replicated across the country hence the reference to the Secretary for State duty

AcTION SHOULd BE TAKEN In my opinion action should be taken to prevent future deaths ad | believe you have the power to take such action:

Responses

Department of Health Social Care Central Government

9 Jun 2018

Noted
The Department of Health acknowledges concerns and states that commissioning of mental health services is a matter for the local NHS. They note that local commissioners have made considerable investment to services to children and young people in the last eighteen months. (AI summary)

View full response

From Jackie Doyle-Price MP Department Parliamentary Under Secretary of State for Mental Health and Inequalities of Health & Department of Health and Social Care 39 Victoria Street Social Care London SW1H OEU Your reference: 31479 Our reference: PFD 1129071 Mr David LI. Roberts HM Senior Coroner; County of Cumbria The Coroner' $ Court Fairfield Station Street Cockermouth Cumbria CA13 9PT 9 June 2018 Jeo A kose4. Thank you for your letter of 16 April to the Secretary of State for Health and Social Care about the death of Miss Karen Jane Edgar: Iam responding as Minister with portfolio responsibility for mental health and I am grateful for the additional time in which to do so. Iwould first like to explain that the commissioning of mental health services in Cumbria is a matter for the local NHS. Inote that you have issued your report to local commissioners, the North Cumbria and the Morecambe Clinical Commissioning Groups (CCGs), as well as the Cumbria Partnership NHS Foundation trust, and I hope their response will be helpful. [am advised by local commissioners that acknowledged that service provision for children and young people with emotional mental health and wellbeing problems needed to be increased, and in the last eighteen months; there has been considerable investment made to services: This has included service improvements for example, to the enhanced crisis service, the development of a community-based eating disorder service, earlier intervention services, preventative work and mental health promotion. Iam further advised that local commissioners acknowledge that there have continued to be delays in referrals for therapy; including family therapy: and that there are challenges with recruiting the specialist workforce; both medical and nursing; The Bay ' they

Cumbria Transforation Plan' , sets out how the Iocal health system will improve the quality of access and care in mental health services for children and young people, and understand, continues to be refined according to local need. Your report makes the that many of the failings identified in the care and treatment provided to Miss Edgar were resonant in the publication of the Care Quality Commission 's (CQC s) inspection report early this This is, of course, concerning and we are clear that the Cumbria Partnership NHS Foundation Trust, and its commissioners, must take action to ensure the provision ofhigh quality, safe, sustainable care. Iam informed that local commissioners are working with the Trust to develop commissioning intentions for children's and adult mental health services that include the consideration of strategic partnerships with the Northumberland Tyne and Wear NHS Foundation Trust and the Lancashire Care NHS Foundation Trust with the aim to deliver more sustainable and robust services. Iam also assured that the CCGs are working to implement an action plan to address the issues raised in your Report: Ata national level, I would like to assure you that improving the quality of access and care in mental health services for children and young people is a priority for this Government; aS set out in Future in Mind' , the Five Year Forward View for Mental Health" and, most recently, the Green Paper on transforming children and young people'$ mental health services We are committed to ensuring our children and young people, and their families, get the support need at the right time. The Government is already making an additional €1.4 billion available, which includes E150 million for eating disorders, to improve mental health services for children and young people with mental health problems. http: WWw northcumbriaccg nhs uklabout-us kex-policies-and-documents policies cumbria-local-transfonalion- plan___cYp-ewmh refresh 180224_finaLpdf http: WWvw CgC Org uklproviderIRNN https:! www LovuklgovemmenUpublications improving-mental health-services for-young-people https; WWW englandnhs uklwp contenuuploads/2016 02 Mental Health Taskforce EYEV-finalpdf htps: Lwww_Lov uklgovermment consultations/transforming-children-and-voung-peoples-mental-health-provision-a - green-paper point year?. key - they

Department of Health & Social Care The Green Paper includes plans to improve access to services and mental health support in schools including: Incentivising every school and college to identify and train a senior designated mental health lead to improve prevention work; Creating brand new mental health support teams working directly with schools and and Piloting a new four week waiting time for NHS children and young people'$ mental health services_ Additional funding of over €300 million will be made available post consultation: The consultation closed on 2 March 2018 and we are currently finalising the response to the consultation, which will be published in due course_ Furthermore, NHS England has developed a major service transformation programme, Children and Young People Improving Access to Psychological Therapies" to significantly reshape the way services for children and young people are commissioned and delivered. This includes, in partnership with Health Education England, the training of existing staff to deliver evidence based interventions As part of the programme, services in Cumbria receive outreach service development support from the training provider to embed the principles of collaborative, evidence- based and outcome-focused care across all teams and services delivering care (NHS, local authority and voluntary sector). In addition; NHS England has invested in the children and young people's Mental Health Improvement Team (MHIT) which consists of one national team and a local team in each clinical network The MHIT provides local support to individual and groups of CCGs, Sustainability Transformation Programmes and Integrated Children's Systems which support the implementation of national policy into local delivery: On the matter of funding for mental health services, I would like to point out that spending on mental health has gone up faster than overall NHS funding and is set to continue to rise. Spending on mental health is planned to have increased to a record E11.86 billion in 2017/18. https Iwww englandnhs ukymental-healthycypliapt colleges;

Department of Health & Social Care The recently published NHS planning guidance" states that all CCGs must meet the Mental Health Investment Standard (MHIS) which requires all CCGs to increase their mental health expenditure: We have introduced much greater transparency about mental health expenditure The Mental Health Five Year Forward View Dashboard' , available online, provides detailed breakdown on spend, including by individual CCGs, for the past two financial years [ hope the information [ have provided is helpful. Thank you for bringing your concerns to our attention. JACKIE DOYLE-PRICE hutps: Www enelandnhs uklpublication/refreshing-nhs-plans-for-2018-192 https:Lwww england nhs uklmental health /taskforce imp mh-dashboard Uclu

Sent To

Cumbria Partnership NHS Foundation Trust
Department of Health and Social Care
Morecambe Bay Clinical Commissioning Group
North Cumbria Clinical Commissioning Group

Response Status

Linked responses 1 of 4

56-Day Deadline 12 Aug 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 12th April 2017 commenced an investigation into the death of Karen Jane Edgar. The investigation concluded at the end of the inquest on 13th April 2018. The conclusion of the inquest was Karen was suffering from emotional and behavioural issues and was referred to Child and Adolescent Mental Health Services (CAMHS} in October 2015,aged 15. Her first substantive meeting with her mental health practitioner was on Bth February, 2016, when family work was planned: She did not start individual talking therapy until 7thApril. Family therapy had ceased to be available: After only one more 1:1 session on 2Sth April she was, on Sth seen by a psychiatrist who prescribed fluoxetine-1Omg: In July it was increased to 2Omg: On 29th September she took an overdose of paracetamol, then raised the alarm and received inpatient general hospital attention: Her true intention was not clear: The psychiatrist changed her medication to sertraline which commenced on about 7th March 2017,after only twelve 1:1 sessions. On ZZnd March she was involved in an outburst at school relating to her boyfriend, from whom she had split in February: At the 1:1 on 29th March she was angry and upset and Iater that day researched 'suicide note' on the internet: Sertraline was increased to 1OOmg on 3Oth March: She had convinced herself she was pregnant and told her former boyfriend on 1st April. She admitted to a friend having tried to hang herself: On the evening of 7th April she had an angry exchange with her former boyfriend over the pregnancy issue via text and went home: Whist her parents were not in the house she hanging herself from a dressing gown cord in wardrobe in her bedroom. She was discovered soon afterwards, but despite medical treatment did not recover and was pronounced dead at West Cumberland Hospital at 01.10 hours on &th April She had made a cut in the ligature with a of scissors: Medical cause: Hanging Conclusion: Misadventure; she hanged herself as a gesture intending to be discovered: CIRCUMSTANCES Of The DEATH Karen had been displaving behavioural and anger problems for many months when there was a major incident in August 2015 which resulted in her and her parents seeking help. Despite a referral to CAMHS in October 2015 assessment appointments did not take place until early December and January. Family work was proposed but only two meetings took place before it ceased to be available: Karen did not start 1:1 work until April 2016, nearly six months from first seeing her GP. She only had 13 talking sessions from the first assessment in December 2015 until her death in April 2017 psychiatrist diagnosed her with moderately severe depressive disorder and prescribed antidepressants after only two 1:1 sessions (NICE suggests 4 6 sessions). She was not monitored closely on four changes_ It remains an open question as to whether the introduction of sertraline a month before is implicated in her death: Whilst the mental health worker did her level best it seems that the resources were inadequate to support Karen and she received sub optimal care: The Trust'$ own report revealed a long list of failings including: no care plan; lack of 'packages of care' ; gaps in work force ad skills base; absence of family therapy; failure to re assess risk formally; Ilack of Multi-disciplinary Meetings; absence of holistic approach and not engaging more productively with her school. Many of these issues were themes found to be endemic in the Trust by the CQC in its report of 26 January 2018 and May; sOmg ' pair The drug

Copies Sent To

18.. have also sent it tc CQC; Self Harm Awareness for All Cumbria (Charity), Office of the Children's Commissioner, Head Master Workington Academy; the Press