UK Inquiry Tracker

Peter Usher

PFD Report All Responded Ref: 2016-0428

Date of Report 2 December 2016

Coroner Nadia Persaud

Coroner Area London (East)

Response Deadline est. 16 April 2017

Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)

Judiciary.uk Report PDF

All 2 responses received · Deadline: 16 Apr 2017

Coroner's Concerns (AI summary)

Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from the duty doctor.

View full coroner's concerns

_ The assessing team did not carry out a detailed assessment of Mr Usher; to include not only a personal assessment but also to obtain relevant clinical information from both professional and non-professional sources_ This would have included information from the family and GP_ There was also relevant information available to the paramedics and police that was not elicited by the assessing team: The Trust policy requires that the assessment should be carried out by the duty doctor and member of the Home Treatment Team_ The policy also requires that the doctor must inform the on-call doctor of the arrival discuss the outcome of the assessment with them_ The Home Treatment Team member was not present during the course of the assessment: He was gathering relevant clinical information from a previous Section 136 attendance The information appears to have been requested shortly after 03.00 and not received until around 04*47 . This was partly due to safe haven procedures which had to be complied with, before a fax could be sent: The Home Treatment team member attended as the assessment was wrapping up. The on-call doctor was not informed of Mr Usher: The Trust policy requires that an AMHP (Approved Mental Health Professional) be notified of the planned assessment: This also did not take place: The police had received contact from family members whilst they were present at the hospital, confirming the concerns of family members due to the text received This was not passed on to the hospital staff. It became apparent the course of the Inquest that the police also had access to information which was relevant to the circumstances of the preceding events which would have been relevant to the mental state of the deceased: It would appear that inadequate questions were asked by the receiving hospital team in relation to the circumstances leading to admission: The junior doctor gave evidence to confirm that he was the only doctor available for 1-wards and 200 patients_ It would appear from information provided by the Trust; that the number of Section 136 assessments is increasing substantially and therefore there is a concern in relation to adequate medical staffing: The evidence during the course of the Inquest the evidence received from the independent psychiatrist raised a number of concerns in relation to the quality of the overall assessment and risk assessment carried out by the duty doctor. No issues relating to the medical input were identified in the Trust'$ own Root Cause Analysis: Further concern was raised during the course of the Inquest by the apparent lack of insight by the duty doctor and by the apparent inability to reflect on practice_ It is unclear from the evidence heard during the course of the Inquest whether there is any audit of clinical decision making during Section 136 assessments. The Section 136 policy contains a 6 hour target for assessments to be completed. Section 136 itself; allows a period of up to 72 hours_ It is unclear from the evidence as to whether the 6 hour limit places undue pressure upon staff to carry out assessments without gathering all of the available relevant evidence. There were inefficiencies in practice which resulted in the member of the Home Treatment Team missing the 136 assessment. He had to wait for approximately hour 45 minutes for clinical information to be provided. He had to go through Safe Haven procedures and to wait for a fax An email to a secure email address may have avoided these delays. and during and

Responses

North East London NHS Foundation Trust NHS / Health Body

24 Jan 2017

Action Planned
North East London NHS Foundation Trust is undertaking a series of actions including sending FOI requests to other trusts, reviewing and updating S136 guidance and policy, creating a secure NHS net account for the S136 suite, and holding a board workshop to discuss SI investigations. They will also explore inviting the Senior Coroner to deliver a presentation. (AI summary)

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Dear Ms Persaud, Re: Inquest touching upon the death of Mr Peter Usher Response to Regulation 28 report refer to a Regulation 28 report dated 2nd December 2016 The Trust is committed to continuously review its service for the purposes of improving quality of care and patient safety and am grateful for bringing these issues to my attention: The Trust has given continues to give the most serious consideration to the concerns regarding the care provided to Mr Usher; which were highlighted in the Regulation 28 report: Please find enclosed the Trust's action plan to address the issues identified in Regulation 28 report

Borough Mental Team Police / Law Enforcement

Action Planned
The Borough Mental Team has identified four areas for improvement: handover of patients between the police and 136 suite staff; filing and storage of 136 paperwork; supporting officers dealing with 136 incidents; and training. Changes to Form 434, a review meeting planned for early February and a video presentation with Mrs Persaud for training are planned. (AI summary)

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This report has been compiled in response to the Regulation 28 Report to Prevent Future Deaths issued by the Senior Coroner for the Coroner area of East London Mrs Naida Pesraud. A number of points were highlighted by Mrs Persuad when looking into the tragic circumstances leading to the death of Mr Usher. Whilst the Metropolitan Police were only mentioned briefly during point 5.4, which highlighted a distinct lack of communication given the circumstances between the police officers and staff from Goodmayes Hospital, It was considered appropriate to conduct an internal review of the way Havering Borough deal with incidents involving Mental Health: Through this investigation four areas were identified for improvement Handover of patients between the police and 136 suite staff 2 Filing and Storage of 136 paperwork 3_ Supporting officers dealing with 136 incidents Training Handovers
1.1 The s136 paperwork completed by officers on the street is Form 434. The form has two particular areas that by their description can create ambiguity when completing them_ The first is towards the top where it has the words "Friends/Family' and a space adjacent to it for the officer to fill out: believe this needs to be more specific and should be changed to "Next of Kin: This will give the officers more clarity when completing the form and eliminating the potential risk of important information being missed. The second is further down and reads "Name of person handing over too" then as above there is a space adjacent for the officer to complete. This leaves some doubt as to whether the person accepting responsibility needs to sign. Under the s136 Pathway it clearly states that a signature is required. However this is not always done leaving both Goodmayes and the Police open to criticism. By reducing the section mentioned above and adding a "signature" box this legal requirement would be complied with. These adaptions would have to be passed through the Metropolitan Police for approval. However this process is invariably lengthy, there is additionally the consideration that the MPS , will be moving to digital paperwork; as such it is unknown whether the proposal will be accepted:
1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite_ The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person. 2 and storage of 136 Paperwork
2.1 Traditionally all 136 paperwork would be completed and retained securely for a period between 7-10 years_ This causes uS with difficulties should the information from the original copy need to be viewed remotely. In addition when someone is detained under s136 an intelligence report would be created but wouldn't always key Filing

provide the full details of what was recorded on the 136 but more of the circumstances of how police came to be in contact with the patient: This resulted in information from the form 434 being missed. To rectify this, a new system has been implemented whereby all paperwork is scanned and attached to the intelligence report. The digital paperwork is then stored on an internal server. This is important should we have occasion to deal with a repeat patient as it will enable us to more accurate intelligence background to the individual.
2.2 The form 434 once completed now has an index able system requiring the completing officer to obtain a reference number which is cross referenced between the intelligence report and the adult come to notice (ACN) report: These are filed in monthly sections both digitally and physically enabling easier access.
3. Supporting officers dealing s136 incidents
3.1 Since the introduction of the s136 Pathway in late 2016 there is now guidance and clarity around who takes what responsibility and when: A streamlined flowchart has been created giving the officers on the street a clear understanding of what is expected of them, the LAS and Goodmayes staff: This has been cross referenced with the 8136 Pathway to dispel any myth or hearsay over roles and responsibilities_ NELFT have viewed the document and are proposing to hold a copy within the reception area of the 136 suite. This has been sent to the Metropolitan Police Territorial Policing (TP) Mental Health team as a proposal to be send out across all boroughs within the London: Training
4.1 Giving officers on the street the correct training and development is paramount to providing the highest levels of service to the public It is important to appreciate that police officers are not mental health experts. However it is important for them to have a better understanding of what signs and symptoms correlate to what illness and how patients may behave if have a particular illness. After liaising with NELFT have agreed to provide training in three areas: a) Signs and symptoms of common mental health concerns b) NHS departments that may be able to assist as an alternative to 136 Police Officers own mental wellbeing
4.2 Mrs Persaud herself has very kindly agreed to provide a video presentation giving an insight into 5136, Coroners Court; what is a regulation 28 notice and the role of a coroner.
4.3 We are currently in discussions with who specialises in inquiries and claims against the police. If agreed, this give the officers a different perspective of how they deal with mental health: Time Scales
1.1 There is no realistic time scale that can be attributed to this point: The Metropolitan Police are trying to move to digital policing by 2020. This report has been directed to our policy unit, Central Mental Health Team and Legal department for consideration. NELFT are also going to petition for the form to be changed: gain they they will

1.2 There is a review meeting planned for early February for a progress report: am confident that by the end of February to mid March this will be completed:
2.1 This was implemented in November 2016
2.2 This was implemented in January 2017
3.1 A circulation email will be sent before the end of January. Copies of the 136 Pathway along with the flowchart have been left in the supervisors office and within the GPC (command unit consisting of Duty Inspector and Hot Sergeant amongst other assets) as points of reference
4.1 With the amalgamation of Barking & Dagenham, Redbridge and Havering boroughs training is currently undergoing vast transformation. At the moment the only estimated timescale is the latter part of 2017 (August to December)_
4.2 Mrs Persaud has been kind enough to offer her time after July 2017 to produce the video presentation.
4.3 Iam currently in process of liaising with Mr Thomas regarding his participation in the training package Mr Usher's death is one of tragic circumstances and the Metropolitan Police, in particular Havering Borough offer our condolences and deepest sympathies to his family. as an organisation are dedicated to providing the highest levels of service to the public. We hope that the procedures, training and enhanced working relationships that have been developed due to this report will go some way to preventing any future deaths_ Respectfully submitted for your consideration Police Sergeant Borough Mental Health Liaison Officer the We

Sent To

North East London NHS Trust

Response Status

Linked responses 2 of 1

56-Day Deadline 16 Apr 2017

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

On the January 2016 commenced an investigation into the death of Peter Daniel Usher The investigation concluded at the end of the Inquest on the 29th November 2016. The conclusion of the Inquest was a narrative conclusion: Mr Usher took his own life. This was in part because the risk of his doing so was not fully and carefully assessed and appropriate precautions were not taken to prevent him doing so.

Circumstances of the Death

Mr Usher was a 39 year old gentleman. From January 2015 he had presented to his GP on a number of occasions complaining of symptoms of depression. In the very early hours of the 28/h December 2015, Mr Usher sent a text to his brother which indicated possible suicidal intentions: At around 01.37 he was seen entering the grounds of the Bower Park Academy school: Police were called and found him with a deliberately sharpened twig held to his neck_ Mr Usher also climbed up a tree in the presence of the police officers_ noted that a laptop and a belt were already in the tree The belt was tied to a branch of the tree and in the presence of the officers Mr Usher tied the other end of the belt around his neck threatened to jump: Mr Usher explained that he had just received some upsetting news about his relationship. He also admitted to drinking whiskey and taking cocaine that evening: The officers were able to talk Mr Usher down and he had to be tasered for his own safety: He was detained by the police under Section 136 of the Mental Health Act and taken into the Section 136 suite at Goodmayes Hospital Mr Usher was taken to hospital at 02.56. The duty doctor and ACAT member were informed: The ACAT member set about checking records for prior psychiatric contact: Information was gathered from a previous attendance within another Trust under Section 136 in February 2015. A section 136 assessment took place by a junior doctor and the duty nursing officer: A decision was made to discharge Mr Usher from Section 136 at 04.50. He left the hospital at 05.00 on the 28/h December 2015. From the evidence available at the Inquest it is likely that Mr Usher returned to the Bower Park Academy School on the 29ih December 2015 and hung himself from a branch of a tree_in the school grounds His body was not located until the 21 January 27th They and

Action Should Be Taken

In my opinion action should be taken to prevent future deaths believe you have the power to take such action_