Leslie Morrison
PFD Report
Partially Responded
Ref: 2016-wp25337
Coroner's Concerns (AI summary)
No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental health condition did not accompany him to the hospital; the coroner suggests policies to ensure up-to-date information is provided upon admission or discharge.
View full coroner's concerns
1. Although it is appreciated that the events in question occurred later in 2014 following the Cheshire West case, it is a matter of concern that in the community, no formal mental capacity assessment was undertaken and no consideration of a DoLS authorisation was undertaken.
2. Consequently, upon his admission to hospital, it was not recognised that he lacked mental capacity. There was no formal assessment and he was treated as an ordinary patient.
3. Details of his mental health condition and in particular his care plan did not accompany him and/or were not supplied by his carers or his care co-ordinator to the hospital, but nor did the hospital check or request information from those looking after him in the community. The concern is that in this case, the deceased's death was avoidable and had there been appropriate communication between all those looking after him, steps would have been taken to ensure his oral diet complied with his current SALT assessment pending a review. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation (whether that be a charity or a private organisation) should have policies and protocols which are applied to ensure that up to date information is provided upon admission to or discharge from hospital.
2. Consequently, upon his admission to hospital, it was not recognised that he lacked mental capacity. There was no formal assessment and he was treated as an ordinary patient.
3. Details of his mental health condition and in particular his care plan did not accompany him and/or were not supplied by his carers or his care co-ordinator to the hospital, but nor did the hospital check or request information from those looking after him in the community. The concern is that in this case, the deceased's death was avoidable and had there been appropriate communication between all those looking after him, steps would have been taken to ensure his oral diet complied with his current SALT assessment pending a review. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation (whether that be a charity or a private organisation) should have policies and protocols which are applied to ensure that up to date information is provided upon admission to or discharge from hospital.
Responses
Action Planned
The Trust will discuss the coroner's letter at the Clinical Effectiveness Committee to consider how to address the concerns raised regarding information transfer and mental capacity assessments. They are also considering the inclusion of safeguarding at quarterly Audit and Clinical Effectiveness Days. (AI summary)
The Trust will discuss the coroner's letter at the Clinical Effectiveness Committee to consider how to address the concerns raised regarding information transfer and mental capacity assessments. They are also considering the inclusion of safeguarding at quarterly Audit and Clinical Effectiveness Days. (AI summary)
View full response
Dear Mr Meadows
Re: Mr Leslie Morrison – Regulation 28: Report to Prevent Future Deaths
I have now had the opportunity to look into the concerns you raise in respect of this case. The response required from Central Manchester University Hospitals NHS Foundation Trust was relating to two specific points:
1. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation should have policies and protocols which are applied to ensure that up to date information about patients particular conditions (both mental and physical) are supplied between those caring for the patient when they are admitted to hospital, and back into the community when they are discharged.
2. It is suggested that in practice on admission to hospital an appropriate review of a patient’s records and care plan should trigger a mental capacity assessment and an application for a DoLS authorisation if appropriate.
For ease I will respond to each of your points in turn.
You note that on Mr Morrison’s admission to the Manchester Royal Infirmary his carers did not provide an up to date care plan, and the acute hospital staff did not actively seek to receive a copy of his care plan from either his carers or primary care.
Whilst in the community Mr Morrison had been assessed by the Speech and Language Team as requiring supervision whilst eating, and for a period of 30 minutes after to ensure that he remained safe. As this information was not passed on to the acute team this was not continued whilst he was in hospital. The admission documentation and nursing assessments on the Acute Medical Unit when Mr Morrison was admitted note that he took diet and fluids normally and was not noted to have any swallowing difficulties; as a result of this no referrals were made for a Speech and Language Therapy assessment. He was however on a soft diet, and having discussed this with the Speech and Language Therapy team, they have confirmed that an egg mayonnaise sandwich would be acceptable as part of a “soft normal diet” with the caveat that if the bread had a hard crust, the crust would need to be cut off. Had the acute team received, or actively sought out, information regarding Mr Morrison’s
nutritional care plan and feeding requirements, the 30 minute observation period would have been implemented which may have meant that he received more timely intervention when he aspirated after eating.
With regards to the handover of information between care environments, I am in agreement that it is a matter of good practice to hand over all salient care issue. This is universally accepted in the NHS and there are many examples of good practice guidance available for this purpose. Achieving effective and safe hand over in all circumstances, particularly for complex and vulnerable cases, remains a considerable concern in all parts of the public health and social care sector.
It is accurate to say that handover between acute and community services, and vice versa, for all vulnerable adults remains at times of an inadequate quality and consistency, as was the case for Mr Morrison. Remedy for this is a system wide problem however we need to take local responsibility for ensuring that this takes place for patients within our care.
Currently as a Trust we do not have a formal policy in place for the sharing of up to date information for patients who are vulnerable or have complex conditions. Whilst staff will informally liaise with care agencies or primary care, this is ad hoc and not an embedded process therefore relies on the staff providing care to a patient to proactively consider the information that may be held elsewhere. There are exceptions to this however, such as patients with learning disabilities, where there is a formal process in place through the use of their LD passport; however this is not consistent across other patient groups. As a result of the findings of this case we will implement a Trustwide initiative regarding the development of a policy or pathway for complex and vulnerable patients which will include proactively gathering information from health providers outside of the Trust. This will include representation from all of our hospitals and Divisions to ensure that this is implemented across all of our services.
You also note in your letter that it was apparent that Mr Morrison lacked mental capacity however a DoLS application was not completed whilst he was in the community or whilst in was an in-patient at the Manchester Royal Infirmary.
As I am sure you are aware, mental capacity (as defined in the Mental Capacity Act 2005) is decision specific and a finding of ‘lack of mental capacity’ alone is not sufficient to justify a DOLS emergency or standard authorisation. This requires a finding of lack of mental capacity to make decisions about location and manner of care and judgement about the specific manner of care in place at the material time. With regards to a DOLS emergency or standard authorisation, this is about the manner in which a person is cared for not about the care provided per se. It is therefore a matter of judgement for the responsible person with overall responsibility for the environment in which a person is cared for, to decide whether there has been or is a risk of an Article 5 breach in which case authorisation can be sought.
Currently when patients are admitted to the hospital an assessment is made as to whether there are any apparent concerns with their ability to make decisions about their care, in order to ensure that we are providing the most appropriate care for patients. This is an on-going process and can be both formal and informal to ascertain if a patient understands where they are and what is happening to them, and if they can consent to whatever care and treatment is being undertaken. If there is any doubt about their inability to understand, consent to treatment or make decisions about their care and treatment, a mental capacity assessment will be completed which will be decision specific. This will support staff to make appropriate decisions about whether a patient lacks capacity. If it is assessed that a patient lacks capacity, it will be ascertained if additional safeguards are needed and if these additional restrictions and/or restraint used would deprive a person of their liberty. If this was
the case then a Deprivation of Liberty Safeguard application would be made.
The Trust is in the process of implementing a transformation project regarding a delirium tool and a frailty flag to help identify those patients who may have reduced capacity. The Trust are working with Patientrack, our partners for the electronic Early Warning Score system, to embed a frailty screen in patients aged over 75 which would then identify patients requiring a comprehensive geriatric assessment. The next stage would be to embed a delirium screen into Patientrack. This work continues to progress and currently a pilot of frailty screening, CGA and delirium screening is taking place at our Trafford site, from which the initial feedback is positive. This will then be developed to produce a unified tool across Trafford and central site and support the care provided to our vulnerable, frail and elderly population.
With regards to staff training around mental capacity and DoLS, I can confirm that we have monthly DoLS training sessions in place regarding awareness of the process and the completion of DoLS and mental capacity assessments. In addition there have also been sessions arranged with our Solicitor partnership firm for external training sessions to be held.
In addition we also mandate within the Trust that all registered nurses complete level 3 Adult Safeguarding training, which is the most advanced safeguarding training we offer clinicians; DoLS and mental capacity is covered within the body of this training. The safeguarding team also offer bespoke sessions to areas who require further support or detail regarding the completion of DoLS.
We are also considering the inclusion of safeguarding at each of our quarterly Audit and Clinical Effectiveness Days, focusing in particular on DoLS and mental capacity. This will be discussed further and plans for implementation made.
Moving forward and in order to improve the consideration given to mental capacity assessments and DoLS authorisations, your letter will be discussed at the Trust Clinical Effectiveness Committee to note your concerns and consider how this should be addressed. Any further action will then be monitored via this committee and allocated to the relevant leads.
Please accept my assurances that lessons have been learned from this case and appropriate actions have been put in place to address the issues that you raise. I am confident that these actions will lead to improvements in the care we provide to our patients, particularly those that are vulnerable or have complex conditions.
Re: Mr Leslie Morrison – Regulation 28: Report to Prevent Future Deaths
I have now had the opportunity to look into the concerns you raise in respect of this case. The response required from Central Manchester University Hospitals NHS Foundation Trust was relating to two specific points:
1. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation should have policies and protocols which are applied to ensure that up to date information about patients particular conditions (both mental and physical) are supplied between those caring for the patient when they are admitted to hospital, and back into the community when they are discharged.
2. It is suggested that in practice on admission to hospital an appropriate review of a patient’s records and care plan should trigger a mental capacity assessment and an application for a DoLS authorisation if appropriate.
For ease I will respond to each of your points in turn.
You note that on Mr Morrison’s admission to the Manchester Royal Infirmary his carers did not provide an up to date care plan, and the acute hospital staff did not actively seek to receive a copy of his care plan from either his carers or primary care.
Whilst in the community Mr Morrison had been assessed by the Speech and Language Team as requiring supervision whilst eating, and for a period of 30 minutes after to ensure that he remained safe. As this information was not passed on to the acute team this was not continued whilst he was in hospital. The admission documentation and nursing assessments on the Acute Medical Unit when Mr Morrison was admitted note that he took diet and fluids normally and was not noted to have any swallowing difficulties; as a result of this no referrals were made for a Speech and Language Therapy assessment. He was however on a soft diet, and having discussed this with the Speech and Language Therapy team, they have confirmed that an egg mayonnaise sandwich would be acceptable as part of a “soft normal diet” with the caveat that if the bread had a hard crust, the crust would need to be cut off. Had the acute team received, or actively sought out, information regarding Mr Morrison’s
nutritional care plan and feeding requirements, the 30 minute observation period would have been implemented which may have meant that he received more timely intervention when he aspirated after eating.
With regards to the handover of information between care environments, I am in agreement that it is a matter of good practice to hand over all salient care issue. This is universally accepted in the NHS and there are many examples of good practice guidance available for this purpose. Achieving effective and safe hand over in all circumstances, particularly for complex and vulnerable cases, remains a considerable concern in all parts of the public health and social care sector.
It is accurate to say that handover between acute and community services, and vice versa, for all vulnerable adults remains at times of an inadequate quality and consistency, as was the case for Mr Morrison. Remedy for this is a system wide problem however we need to take local responsibility for ensuring that this takes place for patients within our care.
Currently as a Trust we do not have a formal policy in place for the sharing of up to date information for patients who are vulnerable or have complex conditions. Whilst staff will informally liaise with care agencies or primary care, this is ad hoc and not an embedded process therefore relies on the staff providing care to a patient to proactively consider the information that may be held elsewhere. There are exceptions to this however, such as patients with learning disabilities, where there is a formal process in place through the use of their LD passport; however this is not consistent across other patient groups. As a result of the findings of this case we will implement a Trustwide initiative regarding the development of a policy or pathway for complex and vulnerable patients which will include proactively gathering information from health providers outside of the Trust. This will include representation from all of our hospitals and Divisions to ensure that this is implemented across all of our services.
You also note in your letter that it was apparent that Mr Morrison lacked mental capacity however a DoLS application was not completed whilst he was in the community or whilst in was an in-patient at the Manchester Royal Infirmary.
As I am sure you are aware, mental capacity (as defined in the Mental Capacity Act 2005) is decision specific and a finding of ‘lack of mental capacity’ alone is not sufficient to justify a DOLS emergency or standard authorisation. This requires a finding of lack of mental capacity to make decisions about location and manner of care and judgement about the specific manner of care in place at the material time. With regards to a DOLS emergency or standard authorisation, this is about the manner in which a person is cared for not about the care provided per se. It is therefore a matter of judgement for the responsible person with overall responsibility for the environment in which a person is cared for, to decide whether there has been or is a risk of an Article 5 breach in which case authorisation can be sought.
Currently when patients are admitted to the hospital an assessment is made as to whether there are any apparent concerns with their ability to make decisions about their care, in order to ensure that we are providing the most appropriate care for patients. This is an on-going process and can be both formal and informal to ascertain if a patient understands where they are and what is happening to them, and if they can consent to whatever care and treatment is being undertaken. If there is any doubt about their inability to understand, consent to treatment or make decisions about their care and treatment, a mental capacity assessment will be completed which will be decision specific. This will support staff to make appropriate decisions about whether a patient lacks capacity. If it is assessed that a patient lacks capacity, it will be ascertained if additional safeguards are needed and if these additional restrictions and/or restraint used would deprive a person of their liberty. If this was
the case then a Deprivation of Liberty Safeguard application would be made.
The Trust is in the process of implementing a transformation project regarding a delirium tool and a frailty flag to help identify those patients who may have reduced capacity. The Trust are working with Patientrack, our partners for the electronic Early Warning Score system, to embed a frailty screen in patients aged over 75 which would then identify patients requiring a comprehensive geriatric assessment. The next stage would be to embed a delirium screen into Patientrack. This work continues to progress and currently a pilot of frailty screening, CGA and delirium screening is taking place at our Trafford site, from which the initial feedback is positive. This will then be developed to produce a unified tool across Trafford and central site and support the care provided to our vulnerable, frail and elderly population.
With regards to staff training around mental capacity and DoLS, I can confirm that we have monthly DoLS training sessions in place regarding awareness of the process and the completion of DoLS and mental capacity assessments. In addition there have also been sessions arranged with our Solicitor partnership firm for external training sessions to be held.
In addition we also mandate within the Trust that all registered nurses complete level 3 Adult Safeguarding training, which is the most advanced safeguarding training we offer clinicians; DoLS and mental capacity is covered within the body of this training. The safeguarding team also offer bespoke sessions to areas who require further support or detail regarding the completion of DoLS.
We are also considering the inclusion of safeguarding at each of our quarterly Audit and Clinical Effectiveness Days, focusing in particular on DoLS and mental capacity. This will be discussed further and plans for implementation made.
Moving forward and in order to improve the consideration given to mental capacity assessments and DoLS authorisations, your letter will be discussed at the Trust Clinical Effectiveness Committee to note your concerns and consider how this should be addressed. Any further action will then be monitored via this committee and allocated to the relevant leads.
Please accept my assurances that lessons have been learned from this case and appropriate actions have been put in place to address the issues that you raise. I am confident that these actions will lead to improvements in the care we provide to our patients, particularly those that are vulnerable or have complex conditions.
Sent To
- Central Manchester University Hospitals NHS Foundation Trust
- Manchester Mental Health and Social Care Trust
- Regard Care
Response Status
Linked responses
1 of 3
56-Day Deadline
22 Sep 2016
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 8 January 2015 I commenced an investigation into the death of Leslie John Morrison, aged 82. The investigation concluded at the end of the inquest on 26 July 2016.
The cause of death was found to be: 1a Respiratory and cardiac arrest 1b Acute aspiration of food 11 Ischaemic heart disease and cerebrovascular disease
The conclusion of the inquest was Accident.
The cause of death was found to be: 1a Respiratory and cardiac arrest 1b Acute aspiration of food 11 Ischaemic heart disease and cerebrovascular disease
The conclusion of the inquest was Accident.
Circumstances of the Death
The deceased was 82 years of age and had been born on 21 January 1932. He suffered a chronic enduring mental health condition, namely bipolar disorder. He had been treated for many years with medication to control the condition and had previous informal admissions to psychiatric units. He also suffered from a number of other physical conditions, including atrial fibrillation, bundle branch block, postural hypotension, an abdominal aortic aneurysm, overactive bladder syndrome and osteoarthritis.
He had a supportive and caring family, together with the assistance of a Registered Mental Nurse who acted as his care co-ordinator. In about 2010 he moved to 299 Great Western Street, Rusholme, Manchester, which is supported care accommodation provided by Regard Care. He required 24 hour care and support to meet his considerable needs.
Over a period of time, his physical condition deteriorated and on or about 5 June 2014 he suffered a choking episode when eating a meal. He was admitted to hospital and underwent a procedure to remove an airway obstruction which apparently turned out to be a sprout. His care co-ordinator then requested a SALT swallowing assessment to be undertaken, which resulted in specialist advice that he required a soft diet with supervision during and for 30 minutes following a meal. Advice was also given about the oral ingestion of a number of medication tablets that he was required to take, which needed to be consumed individually with some lubrication. His care plan was altered to specifically record the SALT assessment and recommended regime of supervision and management.
Over the autumn of 2014, his mental health condition deteriorated and his psychiatrist was in the process of reviewing and altering his medication, as he was suffering from persistent low mood. He had a history of imbalance and falls. He required supervision and assistance with all day to day activities, and in particular his personal hygiene. He suffered no further episodes of choking during this period.
On 1 December 2014, he had a dizzy episode and fell to the floor in the shower whilst being supervised. He was admitted to Manchester Royal Infirmary and was seen and assessed originally in the Acute Medical Unit. It was unclear if he had been accompanied to hospital by a carer, but there is no evidence that his detailed care plan accompanied him, and no specific information was provided to the hospital about any particular condition or management in the community.
The investigations ruled out any major emergency pathology, but there was evidence that he was suffering from an infection and he was started on antibiotics. He was then transferred to Ward 46. He was initially moved there on 3 December by one of the junior doctors and his condition appeared to be stable and his Early Warning Scores were 0. On 4 December he was reviewed by a Consultant Physician, who formed the clinical opinion that he was suffering from both a urinary tract and chest infection and his antibiotics were altered. Thereafter his condition remained stable, and gradually improved. Over the next few days the markers for infection reduced, and by 10 December he was considered to be fit enough to be discharged back into the community.
At approximately 1230hrs, he was given an egg mayonnaise sandwich, which had to be taken out of its wrapper by a member of staff, and he was left to eat this unsupervised. About 15 minutes later, he was found in a slumped position on the table with evidence of cyanosis. The emergency buzzer was pulled and immediately the nurse and a junior doctor attempted to begin CPR and remove some food debris from the mouth pending the arrival of the crash team. They arrived very shortly thereafter and further food debris was removed from his upper airways/throat area. Unfortunately their attempts at resuscitation proved unsuccessful and he was pronounced deceased shortly before 1300hrs.
A subsequent post mortem examination established that he died as a result of an acute aspiration of food.
It was apparent from the evidence received by the court that he lacked mental capacity, but was not subject to a DoLS authorisation in the community, nor indeed was it even considered or applied for whilst in hospital. Prior to 10 December 2014, during his last admission, he did not apparently demonstrate any difficulties with consuming food orally. Nor was it noted or recognised that he actually lacked mental capacity. Had the hospital been aware of his SALT assessment, they would have adopted that aspect of his care plan and arranged for a further SALT assessment.
His care co-ordinator was aware of his admission but presumed that his carers would have supplied a copy of his care plan or details of his SALT assessment. She did not contact the hospital direct or his carers to check this. She was not contacted by the hospital nor his carers to check any aspect of his medical history.
His carers did not provide the hospital with a copy of his care plan, and in particular details of his SALT assessment. Nor did the hospital communicate with either his GP, his care co-ordinator or his carers to request any information.
He had a supportive and caring family, together with the assistance of a Registered Mental Nurse who acted as his care co-ordinator. In about 2010 he moved to 299 Great Western Street, Rusholme, Manchester, which is supported care accommodation provided by Regard Care. He required 24 hour care and support to meet his considerable needs.
Over a period of time, his physical condition deteriorated and on or about 5 June 2014 he suffered a choking episode when eating a meal. He was admitted to hospital and underwent a procedure to remove an airway obstruction which apparently turned out to be a sprout. His care co-ordinator then requested a SALT swallowing assessment to be undertaken, which resulted in specialist advice that he required a soft diet with supervision during and for 30 minutes following a meal. Advice was also given about the oral ingestion of a number of medication tablets that he was required to take, which needed to be consumed individually with some lubrication. His care plan was altered to specifically record the SALT assessment and recommended regime of supervision and management.
Over the autumn of 2014, his mental health condition deteriorated and his psychiatrist was in the process of reviewing and altering his medication, as he was suffering from persistent low mood. He had a history of imbalance and falls. He required supervision and assistance with all day to day activities, and in particular his personal hygiene. He suffered no further episodes of choking during this period.
On 1 December 2014, he had a dizzy episode and fell to the floor in the shower whilst being supervised. He was admitted to Manchester Royal Infirmary and was seen and assessed originally in the Acute Medical Unit. It was unclear if he had been accompanied to hospital by a carer, but there is no evidence that his detailed care plan accompanied him, and no specific information was provided to the hospital about any particular condition or management in the community.
The investigations ruled out any major emergency pathology, but there was evidence that he was suffering from an infection and he was started on antibiotics. He was then transferred to Ward 46. He was initially moved there on 3 December by one of the junior doctors and his condition appeared to be stable and his Early Warning Scores were 0. On 4 December he was reviewed by a Consultant Physician, who formed the clinical opinion that he was suffering from both a urinary tract and chest infection and his antibiotics were altered. Thereafter his condition remained stable, and gradually improved. Over the next few days the markers for infection reduced, and by 10 December he was considered to be fit enough to be discharged back into the community.
At approximately 1230hrs, he was given an egg mayonnaise sandwich, which had to be taken out of its wrapper by a member of staff, and he was left to eat this unsupervised. About 15 minutes later, he was found in a slumped position on the table with evidence of cyanosis. The emergency buzzer was pulled and immediately the nurse and a junior doctor attempted to begin CPR and remove some food debris from the mouth pending the arrival of the crash team. They arrived very shortly thereafter and further food debris was removed from his upper airways/throat area. Unfortunately their attempts at resuscitation proved unsuccessful and he was pronounced deceased shortly before 1300hrs.
A subsequent post mortem examination established that he died as a result of an acute aspiration of food.
It was apparent from the evidence received by the court that he lacked mental capacity, but was not subject to a DoLS authorisation in the community, nor indeed was it even considered or applied for whilst in hospital. Prior to 10 December 2014, during his last admission, he did not apparently demonstrate any difficulties with consuming food orally. Nor was it noted or recognised that he actually lacked mental capacity. Had the hospital been aware of his SALT assessment, they would have adopted that aspect of his care plan and arranged for a further SALT assessment.
His care co-ordinator was aware of his admission but presumed that his carers would have supplied a copy of his care plan or details of his SALT assessment. She did not contact the hospital direct or his carers to check this. She was not contacted by the hospital nor his carers to check any aspect of his medical history.
His carers did not provide the hospital with a copy of his care plan, and in particular details of his SALT assessment. Nor did the hospital communicate with either his GP, his care co-ordinator or his carers to request any information.
Action Should Be Taken
1. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation (whether that be a charity or a private organisation) should have policies and protocols which are applied to ensure that up to date information about patients' particular conditions (both mental and physical) are supplied between those caring for the patient when they are admitted to hospital when they are admitted, and back into the community when they are discharged.
2. It is suggested that in practice on admission to hospital and appropriate review of a patient's records and care plan should trigger a mental capacity assessment and an application for DoLS authorisation if appropriate.
2. It is suggested that in practice on admission to hospital and appropriate review of a patient's records and care plan should trigger a mental capacity assessment and an application for DoLS authorisation if appropriate.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.