Sandra Brotherton
PFD Report
All Responded
Ref: 2016-0400
All 1 response received
· Deadline: 23 Apr 2017
Coroner's Concerns (AI summary)
A sole carer did not have a contingency plan in place for emergencies, a personal assistant's care plan was not clearly documented or provided, and an urgent consultant psychiatrist appointment was difficult to obtain.
View full coroner's concerns
The concerns noted by the Court the course of the Inquest are as follows:
1) Knowing that Sandra was in effect & sole carer there should have been spoke urged help: during clearly discussed contingency plan foi in the event that there was an emergency and Sandra was not able to provide care.
2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person; where there is no suggestion of a lack of capacity, this should be recorded.
3) It was concerning that the Care Co-Ordinator who visited] in August 2014 was not able to obtain a urgent appointment with Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence aS to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of a assault but suggestive of potential issue involving a Mental Health service user and it is for this reason that I do find that_there should have been an attempt to see or speak to to see how he was, after there had been suggestion that he needed to his him immediately
1) Knowing that Sandra was in effect & sole carer there should have been spoke urged help: during clearly discussed contingency plan foi in the event that there was an emergency and Sandra was not able to provide care.
2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person; where there is no suggestion of a lack of capacity, this should be recorded.
3) It was concerning that the Care Co-Ordinator who visited] in August 2014 was not able to obtain a urgent appointment with Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence aS to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of a assault but suggestive of potential issue involving a Mental Health service user and it is for this reason that I do find that_there should have been an attempt to see or speak to to see how he was, after there had been suggestion that he needed to his him immediately
Responses
Action Taken
The Trust has updated its audit tool to include questions about contingency plans for carers, reminded care coordinators to document these plans, and developed a 7-minute briefing on this topic for community mental health teams. The Trust's CPA policy was updated to describe the role of the Consultant Psychiatrist and a 7-minute briefing on responding to crisis calls has been shared with all community based mental health teams in the Trust. (AI summary)
The Trust has updated its audit tool to include questions about contingency plans for carers, reminded care coordinators to document these plans, and developed a 7-minute briefing on this topic for community mental health teams. The Trust's CPA policy was updated to describe the role of the Consultant Psychiatrist and a 7-minute briefing on responding to crisis calls has been shared with all community based mental health teams in the Trust. (AI summary)
View full response
Dear Ms Kearsley, Re: Sandra Brotherton (Deceased) Thank you for your Regulation 28 report dated the 13h December 2016, and for bringing to my attention the concerns you had after hearing all the evidence. Your concerns relevant to Pennine Care have been reviewed, and the Trust's response is outlined below. Concern 1: "Knowing that SB was in effect a sole carer there should have been a clearly discussed contingency plan for DB in the event that there was an emergency and SB was not able to provide care Response: The Trust records audit has been reviewed and amended. This has gone live within services from week commencing 30.01.17 . Question 26 of the audit asks if there are detailed actions to take to managelmitigate risk (e.g. triggerslcrisis and risk management plans): Question 26 also asks if a crisis management contingency / prevention plan is in place. Care Coordinators within Stockport Community Services have been reminded that it is their responsibility to develop contingency plans in collaboration with the identified carer in the event of any emergency situation where they are unable to provide care, such as the care being admitted to hospital: Care Coordinators will ensure this is clearly documented in the service user's care plan: Old
To share the learning highlighted in your concern a 7 minute briefing has been developed regarding contingency plans in the absence of the main carer and this has been shared with all community based mental health teams in the Trust; The briefing recommends that where a serviceluser's care inl the community is reliant on the support of a carer, a contingency plan Ishould be agreed and documented in the care plan for when the main carer is not able to provide care: Community Team Managers have delivered the briefing to teams, t0 reilect on the findings and recommendations in the briefing, to discuss the implicatibn for individual practitioners prattice and for the service or team. Practitioners have been asked to outline the steps they will take to improve practice in Iine with the recommendation. Recommendation: To be discussed at the Tier 4 (Trust-Wide Strategic Group , which oversees Community Mental Health Services) meeting to discuss adding guidance as an addendum to current operational policy for each community based team: Concern 2: "Where a Personal Assistant is integral to the Mental Health Service care plan there should have been a clear and documented record that the care plan should be provided to them If there is an objection to confidential medical information being shared by the relevant person, where there is no suggestion of a lack of capacity, this should be recorded Response: Penhine Care NHS Foundation Trust Care Programme Approach Policy was updated in November 2016 to provide guidance on assessment and CPA care planning to clarify responsibilities and requirements where there are carers funded by direct payments_ The Trust records audit has been reviewed and amended and question 30 of the audit asks if there is evidence carerslothers know who to contact in a crisis, if there is evidence of communication to other agencies involved in the care of the service user, and that other agencies involved in the service user'$ care have received a copy of the plan. This has gone live within services week commencing
30.01.17 . Coordinators within Stockport Community Services have been reminded that in line with the CPA policy, version 12, where a Personal Assistant is in place with individual service users, the Care Coordinator will assess the need to share information with the PA based on risk This must form part of the wellbeing care plan. To share the learning highlighted in this regulation a 7 minute briefing regarding the involvement of a PA in care planning processes has been developed and has been shared with all community based mental health teams in the The briefing recommends that where a Personal Assistant is integral to the Mental Health Service from Care Trust:
care plan there should be a clear and documented record that the care plan should be provided to them and that if there is an objection t0 confidential medical information shared by the relevant person, where there is nq suggestion of a lack of capacity, this should be recorded. Teams haye also been advised to review the updated CPA policy, which includes guidance wHlere carers are funded by direct payments Community Team Managers have delivered the briefing t0 teams, to reflect on the findings and recommendations in the briefing, to discuss the implications fdr individual practitioners practice and for the servicepr team: are hsked to outline the steps will take to improve practice in line with Fecommendations: Recommendation: To be discussed at the Tier 4 meeting to discuss adding guidance as an addendum to current operational policy for each community based team: Concern 3: "It was concerning that the Care Coordinator who visited DB in August 2014 was not able to obtain an urgent appointment with a Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with a dual diagnosis was required: Whilst his medication was increased at this stage he was not seen by a Consultant until October 2014. Response: Pennine Care NHS Foundation Trust Care Programme Approach Policy has been Ypdated in November 2016 to describe the role of the Consultant Psychiatrist with regard to the CPA policy and care policy: This will be discussed at the Tier 4 meeting where confirmation will be sought that community teams have a process for responding to crisis calls. Work around responding to crisis calls completed by Stockport Community Services will feed into the Tier 4 meeting for other boroughs to develop similar guidance locally: Confirmation will be sought that community teams in other boroughs have a process for responding to crisis calls. To share the learning highlighted in this regulation a 7 minute briefing regarding response to crisis calls has been developed regarding crisis calls and has been shared with all community based mental health teams in the Trust, The briefing recommends that community teams need to have triggers for responding to crisis calls and an escalation process in place. Community Team Managers have delivered the briefing to teams, to reflect on the findings and recommendations in the briefing, to discuss the implications for individual practitioners practice and for the service or team: have been asked to outline the steps will take t0 improve practice in line with the recommendation_ being They they . They they'
Recommendation: To be discussed at the Tier 4 meeting to discuss guidance as an addendum to current operational policy for each community based team. In order to provide you with further assurance that the Trust has reviewed all the concerns attach a copY of the action plan that was produced in relation to issues relevant to this particulan case_ hope this response assures you that the Trust takes seriously any concerns that you raised
To share the learning highlighted in your concern a 7 minute briefing has been developed regarding contingency plans in the absence of the main carer and this has been shared with all community based mental health teams in the Trust; The briefing recommends that where a serviceluser's care inl the community is reliant on the support of a carer, a contingency plan Ishould be agreed and documented in the care plan for when the main carer is not able to provide care: Community Team Managers have delivered the briefing to teams, t0 reilect on the findings and recommendations in the briefing, to discuss the implicatibn for individual practitioners prattice and for the service or team. Practitioners have been asked to outline the steps they will take to improve practice in Iine with the recommendation. Recommendation: To be discussed at the Tier 4 (Trust-Wide Strategic Group , which oversees Community Mental Health Services) meeting to discuss adding guidance as an addendum to current operational policy for each community based team: Concern 2: "Where a Personal Assistant is integral to the Mental Health Service care plan there should have been a clear and documented record that the care plan should be provided to them If there is an objection to confidential medical information being shared by the relevant person, where there is no suggestion of a lack of capacity, this should be recorded Response: Penhine Care NHS Foundation Trust Care Programme Approach Policy was updated in November 2016 to provide guidance on assessment and CPA care planning to clarify responsibilities and requirements where there are carers funded by direct payments_ The Trust records audit has been reviewed and amended and question 30 of the audit asks if there is evidence carerslothers know who to contact in a crisis, if there is evidence of communication to other agencies involved in the care of the service user, and that other agencies involved in the service user'$ care have received a copy of the plan. This has gone live within services week commencing
30.01.17 . Coordinators within Stockport Community Services have been reminded that in line with the CPA policy, version 12, where a Personal Assistant is in place with individual service users, the Care Coordinator will assess the need to share information with the PA based on risk This must form part of the wellbeing care plan. To share the learning highlighted in this regulation a 7 minute briefing regarding the involvement of a PA in care planning processes has been developed and has been shared with all community based mental health teams in the The briefing recommends that where a Personal Assistant is integral to the Mental Health Service from Care Trust:
care plan there should be a clear and documented record that the care plan should be provided to them and that if there is an objection t0 confidential medical information shared by the relevant person, where there is nq suggestion of a lack of capacity, this should be recorded. Teams haye also been advised to review the updated CPA policy, which includes guidance wHlere carers are funded by direct payments Community Team Managers have delivered the briefing t0 teams, to reflect on the findings and recommendations in the briefing, to discuss the implications fdr individual practitioners practice and for the servicepr team: are hsked to outline the steps will take to improve practice in line with Fecommendations: Recommendation: To be discussed at the Tier 4 meeting to discuss adding guidance as an addendum to current operational policy for each community based team: Concern 3: "It was concerning that the Care Coordinator who visited DB in August 2014 was not able to obtain an urgent appointment with a Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with a dual diagnosis was required: Whilst his medication was increased at this stage he was not seen by a Consultant until October 2014. Response: Pennine Care NHS Foundation Trust Care Programme Approach Policy has been Ypdated in November 2016 to describe the role of the Consultant Psychiatrist with regard to the CPA policy and care policy: This will be discussed at the Tier 4 meeting where confirmation will be sought that community teams have a process for responding to crisis calls. Work around responding to crisis calls completed by Stockport Community Services will feed into the Tier 4 meeting for other boroughs to develop similar guidance locally: Confirmation will be sought that community teams in other boroughs have a process for responding to crisis calls. To share the learning highlighted in this regulation a 7 minute briefing regarding response to crisis calls has been developed regarding crisis calls and has been shared with all community based mental health teams in the Trust, The briefing recommends that community teams need to have triggers for responding to crisis calls and an escalation process in place. Community Team Managers have delivered the briefing to teams, to reflect on the findings and recommendations in the briefing, to discuss the implications for individual practitioners practice and for the service or team: have been asked to outline the steps will take t0 improve practice in line with the recommendation_ being They they . They they'
Recommendation: To be discussed at the Tier 4 meeting to discuss guidance as an addendum to current operational policy for each community based team. In order to provide you with further assurance that the Trust has reviewed all the concerns attach a copY of the action plan that was produced in relation to issues relevant to this particulan case_ hope this response assures you that the Trust takes seriously any concerns that you raised
Sent To
- Pennine Care NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Apr 2017
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 3Oth November 2016 I concluded the Inquest into the death of Sandra Brotherton date of birth 10.07.1954 who died on the 31.12.14 at her home address in Bredbury Stockport. The cause of death was 1a) Multiple Stab Wounds [recorded that the deceased died on the 31s December 2014 at her home address. She was killed by an individual who had dual diagnosis of paranoid schizophrenia and Aspergers For several the deceased had been in hospital and the individual who had no insight into his illness at been at the home address alone: It is probable that he had not been eating, sleeping or taking his medication this period of time and had experienced breakthrough in his symptoms: When the deceased arrived home he was exhibiting agitated and disturbed behaviour and killed the deceased a few hours after she arrived home Conclusion Unlawful Killing CIRCUMSTANCES OF THE DEATH The Inquest into the death of Sandra_Brotherton was resumed following criminal trial in which the offender; had been sentenced to hospital order. There were matters of concern raised surrounding his involvement with Mental Health Services. had a dual diagnosis of Paranoid Schizophrenia and Aspergers Syndrome He had been sectioned many years ago for a short period of time but had subsequently been cared for at the address by Sandra Brotherton who was predominantly his sole carer: required_prompting to do many daily_tasks including_washing_dressing, Acting days during home eating and taking his medication: was described by several witnesses as someone who had residual symptoms of his psychosis and lacked understanding and insight into his condition. He never accepted that he was unwell Sandra was the of aggressive behaviours and we heard evidence f the arguments which might occur between them and off name of over many years when he called her such as "witch and satan" . Sandra aS the main carer and indeed main person in life who bore the brunt of his behaviour and verbal aggression: Package of Care_in place for) The Court heard how was under the care of mental health services_ He was treated with medication which was reviewed and until 2014 he was under the care of the Community Mental Health Team; EIT. This was then transferred to Recovery and Intervention Team (RIT) Under both services had & care co-ordinator: Indeed the difference on practical level for was the change in his worker: In addition_ had a Personal Assistant which was for through the Direct payments scheme of the local authority who had been in place since 2006. Contingency Given that Sandra was effectively the sole carer forl questions were asked at the Inquest as to a contingency plan in place should Sandra not be in a position to care for At times the evidence on this was interlinked with the plan for respite care but overall the contingency plans for were simply having provided contact details for the Access and Crisis teams and the Home Treatment team and believing that family were close and on hand to provide support. Information Provided to PA and interaction with Mental Health Services confired it was not until after death that he was aware of Jdiagnosis of Schizophrenia His understanding was that Mental_health services were involved because of diagnosis of autism: was clear_that he received his instructions from Sandra. He had little contact withi care cO-ordinator although there were occasions when he would see her. It was clear from the evidence that was included in the care plan for] but as he stated in his evidence, he would not know ifhe was_ The mental health team were not aware when would be on leave the RIT Team confirmed that she would have expected that the RIT team were aware of when the PA was on leave and haveexpected increased visits by the care cO-ordinator during this time also accepted she could have increased her visits had she known the PA would be away. focus calling things paid Plans very would
August 2014 and Incident on the 1801 September The Court heard evidence of involvement withl and Sandra throughout the August and September of 2014. In August 2014 had received call indicating] was unwell and she carried out an urgent home visit: She indicated that she could see he was unwell, he was agitated_she stated though that he was not delusional: At this stage she advised how_ was 0n leave and she to another Dr who agreed to increase Olanzapine medication: The Court also heard that during this time she tried to get an urgent appointment with Consultant Psychiatrist but this was not possible: A month later the Court then heard evidence about the incident which occured on the 18th September: Sandra told her daughter thatL had lashed out and hit her in the face. There was also some evidence she also told her husband who was abroad but may not have told him the full details We know that she told her sister that had hit her; saying that Jhad tripped and had not meant to do it, she was convinced it was a one off: Also told her sister who felt that] had crossed line and Sandra to seek In addition she did tell that had lashed out at her but when asked, she said that she had reported it to care team: Sandra did telephone Mental health services on the 18h September at no stage in any of the conversations did she say that had assaulted her: We know that she did ring saying that he needed to be re-housed immediately: in her evidence described "trying to make sense of the reasons Sandra wanted lout of the property" and recalled her being "vague" She recalled 'it was almost as if Sandra just wanted him out of the house not that she felt at risk" Sandra was asked about risk and told who documented the same that she did not feel at risk December 2014 Sandra was unwell over the Xmas period and had attended hospital on the 22-23r December. She then reattended and was admitted on the 284h December: At no stage were Mental Health services aware of her admission: When she returned home on the 31s December 2014 she was killed a short time later; CORONERS CONCERNS The concerns noted by the Court the course of the Inquest are as follows:
1) Knowing that Sandra was in effect & sole carer there should have been spoke urged help: during clearly discussed contingency plan foi in the event that there was an emergency and Sandra was not able to provide care.
2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person; where there is no suggestion of a lack of capacity, this should be recorded.
3) It was concerning that the Care Co-Ordinator who visited] in August 2014 was not able to obtain a urgent appointment with Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence aS to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of a assault but suggestive of potential issue involving a Mental Health service user and it is for this reason that I do find that_there should have been an attempt to see or speak to to see how he was, after there had been suggestion that he needed to his him immediately ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report; namely by 2"d February 2017 1, the coroner; may extend the period. response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION Ihave sent & copy ofmy report to the Chief Coroner and to the following Interested Persons namely, the family and Iegal representatives of the family of Sandra Brotherton: Iam also under a duty to send the Chief Coroner a copy of your response. leave duty days Your explain
The Chief Coroner may publish either Or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: 08.12.2016 Joanne Kearsley Acting Senior Coroner (Vas 5
August 2014 and Incident on the 1801 September The Court heard evidence of involvement withl and Sandra throughout the August and September of 2014. In August 2014 had received call indicating] was unwell and she carried out an urgent home visit: She indicated that she could see he was unwell, he was agitated_she stated though that he was not delusional: At this stage she advised how_ was 0n leave and she to another Dr who agreed to increase Olanzapine medication: The Court also heard that during this time she tried to get an urgent appointment with Consultant Psychiatrist but this was not possible: A month later the Court then heard evidence about the incident which occured on the 18th September: Sandra told her daughter thatL had lashed out and hit her in the face. There was also some evidence she also told her husband who was abroad but may not have told him the full details We know that she told her sister that had hit her; saying that Jhad tripped and had not meant to do it, she was convinced it was a one off: Also told her sister who felt that] had crossed line and Sandra to seek In addition she did tell that had lashed out at her but when asked, she said that she had reported it to care team: Sandra did telephone Mental health services on the 18h September at no stage in any of the conversations did she say that had assaulted her: We know that she did ring saying that he needed to be re-housed immediately: in her evidence described "trying to make sense of the reasons Sandra wanted lout of the property" and recalled her being "vague" She recalled 'it was almost as if Sandra just wanted him out of the house not that she felt at risk" Sandra was asked about risk and told who documented the same that she did not feel at risk December 2014 Sandra was unwell over the Xmas period and had attended hospital on the 22-23r December. She then reattended and was admitted on the 284h December: At no stage were Mental Health services aware of her admission: When she returned home on the 31s December 2014 she was killed a short time later; CORONERS CONCERNS The concerns noted by the Court the course of the Inquest are as follows:
1) Knowing that Sandra was in effect & sole carer there should have been spoke urged help: during clearly discussed contingency plan foi in the event that there was an emergency and Sandra was not able to provide care.
2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person; where there is no suggestion of a lack of capacity, this should be recorded.
3) It was concerning that the Care Co-Ordinator who visited] in August 2014 was not able to obtain a urgent appointment with Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence aS to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of a assault but suggestive of potential issue involving a Mental Health service user and it is for this reason that I do find that_there should have been an attempt to see or speak to to see how he was, after there had been suggestion that he needed to his him immediately ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report; namely by 2"d February 2017 1, the coroner; may extend the period. response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION Ihave sent & copy ofmy report to the Chief Coroner and to the following Interested Persons namely, the family and Iegal representatives of the family of Sandra Brotherton: Iam also under a duty to send the Chief Coroner a copy of your response. leave duty days Your explain
The Chief Coroner may publish either Or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: 08.12.2016 Joanne Kearsley Acting Senior Coroner (Vas 5
Circumstances of the Death
The Inquest into the death of Sandra_Brotherton was resumed following criminal trial in which the offender; had been sentenced to hospital order. There were matters of concern raised surrounding his involvement with Mental Health Services. had a dual diagnosis of Paranoid Schizophrenia and Aspergers Syndrome He had been sectioned many years ago for a short period of time but had subsequently been cared for at the address by Sandra Brotherton who was predominantly his sole carer: required_prompting to do many daily_tasks including_washing_dressing, Acting days during home eating and taking his medication: was described by several witnesses as someone who had residual symptoms of his psychosis and lacked understanding and insight into his condition. He never accepted that he was unwell Sandra was the of aggressive behaviours and we heard evidence f the arguments which might occur between them and off name of over many years when he called her such as "witch and satan" . Sandra aS the main carer and indeed main person in life who bore the brunt of his behaviour and verbal aggression: Package of Care_in place for) The Court heard how was under the care of mental health services_ He was treated with medication which was reviewed and until 2014 he was under the care of the Community Mental Health Team; EIT. This was then transferred to Recovery and Intervention Team (RIT) Under both services had & care co-ordinator: Indeed the difference on practical level for was the change in his worker: In addition_ had a Personal Assistant which was for through the Direct payments scheme of the local authority who had been in place since 2006. Contingency Given that Sandra was effectively the sole carer forl questions were asked at the Inquest as to a contingency plan in place should Sandra not be in a position to care for At times the evidence on this was interlinked with the plan for respite care but overall the contingency plans for were simply having provided contact details for the Access and Crisis teams and the Home Treatment team and believing that family were close and on hand to provide support. Information Provided to PA and interaction with Mental Health Services confired it was not until after death that he was aware of Jdiagnosis of Schizophrenia His understanding was that Mental_health services were involved because of diagnosis of autism: was clear_that he received his instructions from Sandra. He had little contact withi care cO-ordinator although there were occasions when he would see her. It was clear from the evidence that was included in the care plan for] but as he stated in his evidence, he would not know ifhe was_ The mental health team were not aware when would be on leave the RIT Team confirmed that she would have expected that the RIT team were aware of when the PA was on leave and haveexpected increased visits by the care cO-ordinator during this time also accepted she could have increased her visits had she known the PA would be away. focus calling things paid Plans very would
August 2014 and Incident on the 1801 September The Court heard evidence of involvement withl and Sandra throughout the August and September of 2014. In August 2014 had received call indicating] was unwell and she carried out an urgent home visit: She indicated that she could see he was unwell, he was agitated_she stated though that he was not delusional: At this stage she advised how_ was 0n leave and she to another Dr who agreed to increase Olanzapine medication: The Court also heard that during this time she tried to get an urgent appointment with Consultant Psychiatrist but this was not possible: A month later the Court then heard evidence about the incident which occured on the 18th September: Sandra told her daughter thatL had lashed out and hit her in the face. There was also some evidence she also told her husband who was abroad but may not have told him the full details We know that she told her sister that had hit her; saying that Jhad tripped and had not meant to do it, she was convinced it was a one off: Also told her sister who felt that] had crossed line and Sandra to seek In addition she did tell that had lashed out at her but when asked, she said that she had reported it to care team: Sandra did telephone Mental health services on the 18h September at no stage in any of the conversations did she say that had assaulted her: We know that she did ring saying that he needed to be re-housed immediately: in her evidence described "trying to make sense of the reasons Sandra wanted lout of the property" and recalled her being "vague" She recalled 'it was almost as if Sandra just wanted him out of the house not that she felt at risk" Sandra was asked about risk and told who documented the same that she did not feel at risk December 2014 Sandra was unwell over the Xmas period and had attended hospital on the 22-23r December. She then reattended and was admitted on the 284h December: At no stage were Mental Health services aware of her admission: When she returned home on the 31s December 2014 she was killed a short time later;
August 2014 and Incident on the 1801 September The Court heard evidence of involvement withl and Sandra throughout the August and September of 2014. In August 2014 had received call indicating] was unwell and she carried out an urgent home visit: She indicated that she could see he was unwell, he was agitated_she stated though that he was not delusional: At this stage she advised how_ was 0n leave and she to another Dr who agreed to increase Olanzapine medication: The Court also heard that during this time she tried to get an urgent appointment with Consultant Psychiatrist but this was not possible: A month later the Court then heard evidence about the incident which occured on the 18th September: Sandra told her daughter thatL had lashed out and hit her in the face. There was also some evidence she also told her husband who was abroad but may not have told him the full details We know that she told her sister that had hit her; saying that Jhad tripped and had not meant to do it, she was convinced it was a one off: Also told her sister who felt that] had crossed line and Sandra to seek In addition she did tell that had lashed out at her but when asked, she said that she had reported it to care team: Sandra did telephone Mental health services on the 18h September at no stage in any of the conversations did she say that had assaulted her: We know that she did ring saying that he needed to be re-housed immediately: in her evidence described "trying to make sense of the reasons Sandra wanted lout of the property" and recalled her being "vague" She recalled 'it was almost as if Sandra just wanted him out of the house not that she felt at risk" Sandra was asked about risk and told who documented the same that she did not feel at risk December 2014 Sandra was unwell over the Xmas period and had attended hospital on the 22-23r December. She then reattended and was admitted on the 284h December: At no stage were Mental Health services aware of her admission: When she returned home on the 31s December 2014 she was killed a short time later;
Inquest Conclusion
1) Knowing that Sandra was in effect & sole carer there should have been spoke urged help: during clearly discussed contingency plan foi in the event that there was an emergency and Sandra was not able to provide care.
2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person; where there is no suggestion of a lack of capacity, this should be recorded.
3) It was concerning that the Care Co-Ordinator who visited] in August 2014 was not able to obtain a urgent appointment with Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence aS to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of a assault but suggestive of potential issue involving a Mental Health service user and it is for this reason that I do find that_there should have been an attempt to see or speak to to see how he was, after there had been suggestion that he needed to his him immediately ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report; namely by 2"d February 2017 1, the coroner; may extend the period. response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION Ihave sent & copy ofmy report to the Chief Coroner and to the following Interested Persons namely, the family and Iegal representatives of the family of Sandra Brotherton: Iam also under a duty to send the Chief Coroner a copy of your response. leave duty days Your explain
The Chief Coroner may publish either Or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: 08.12.2016 Joanne Kearsley Acting Senior Coroner (Vas 5
2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person; where there is no suggestion of a lack of capacity, this should be recorded.
3) It was concerning that the Care Co-Ordinator who visited] in August 2014 was not able to obtain a urgent appointment with Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence aS to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of a assault but suggestive of potential issue involving a Mental Health service user and it is for this reason that I do find that_there should have been an attempt to see or speak to to see how he was, after there had been suggestion that he needed to his him immediately ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report; namely by 2"d February 2017 1, the coroner; may extend the period. response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION Ihave sent & copy ofmy report to the Chief Coroner and to the following Interested Persons namely, the family and Iegal representatives of the family of Sandra Brotherton: Iam also under a duty to send the Chief Coroner a copy of your response. leave duty days Your explain
The Chief Coroner may publish either Or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: 08.12.2016 Joanne Kearsley Acting Senior Coroner (Vas 5
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.