Dennis Bennett
PFD Report
Partially Responded
Ref: 2016-0142
Coroner's Concerns (AI summary)
There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their "place-specific" nature, and their appropriate use in relation to Mental Health Act detentions. This risks negatively impacting other patients' care.
View full coroner's concerns
The concerns noted by the Court during the course ofthe Inquest are as follows:
1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act:
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. The decision to apply for a DOLS was initially made at & time when the decision was for him to be moved to nursing home care Indeed the evidence provided by the family was that DOLS application was necessary so that he could be moved to the nursing home: There appears to be a lack of 'understanding aS to the fact that DOLS are place specific. The deceased was then on stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLs was applied for as opposed to treating the deceased in his best interests. Whilst in this case the application did not impact on his care or treatment there is a concern that & lack of understanding and differing information may and could impact on other patients.
1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act:
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. The decision to apply for a DOLS was initially made at & time when the decision was for him to be moved to nursing home care Indeed the evidence provided by the family was that DOLS application was necessary so that he could be moved to the nursing home: There appears to be a lack of 'understanding aS to the fact that DOLS are place specific. The deceased was then on stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLs was applied for as opposed to treating the deceased in his best interests. Whilst in this case the application did not impact on his care or treatment there is a concern that & lack of understanding and differing information may and could impact on other patients.
Responses
Action Planned
Senior clinical staff will be provided with further bespoke training about Deprivation of Liberty safeguards. The Trust's Clinical Improvement Lead Nurse for Dementia, Older People and Carers Services is currently undertaking a review of end of life care and will consider the most appropriate legal framework to use. (AI summary)
Senior clinical staff will be provided with further bespoke training about Deprivation of Liberty safeguards. The Trust's Clinical Improvement Lead Nurse for Dementia, Older People and Carers Services is currently undertaking a review of end of life care and will consider the most appropriate legal framework to use. (AI summary)
View full response
Dear Sirs RE: Dennis BENNETT (Deceased) Please find attached a copy of the response to the Regulation 28 Report received from the Chief Executive of Greater Manchester West Mental Health NHS Foundation Trust, Yours faithfully Miss ~Kearsley Area Coroner John $ Pollard LIB. Hons, Senior Coroner Coroner'$ Court Mount Tabor Street Joanne Kearsley LI,B. Hons Grad Dip Psych; Area Coroner Stockport SKI 3AG Telephone: 0161 474 3993 Facsimile: 0161 474 3994 WWW . coronersmanchestersouth org.uk May "
Greater Manchester West [NHS] Mental Health NHS Foundation Trust Trust Management Offices 18t Floor; The Curve Bury New Road Prestwich Manchester M25 3BL Ref:BHIkearsley19.05.16 Tel: 0161 3581602 23 6y 70.5 19th 2016 Hc Web: WWwgmw nhs.uk WE ARE SOCIAL Miss Kearsley YoufTube Manchester South Coroner's Court Mount Tabor Street Stockport SK1 3AG Dear Miss Kearsley Re: Regulation 28: Dennis Bennett (Deceased) am responding to Regulation 28 you issued to the Trust on 11th April 2016. Whilst Mr Bennett's death was expected on the ward and the concerns you raise are not related to his death; or his care; or treatment;, you note that there is a concern that a lack of understanding and differing information about the Deprivation of Liberty (DoLs) process may and could impact on other patients. For ease will answer each concern separately. You note that the Trust staff completed an application for an urgent DoLs at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act The use of DoLs is rare within the Moorside Unit and Bollin/Greenway Ward. In order to ensure staff have a good understanding of the DoLs process and its relationship to the Mental Health Act senior clinical staff will be provided with further bespoke training about DoLs which will incorporate the concerns you raise. A further concern was raised that there was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. In order to avoid any further miscommunications and because the use of DoLs o the Moorside Unit is rare the Mental Health Act Administrator has been asked to ensure summary email is sent to the Council when iaking advice. This wili ensure any miscommunications are picked up by either party promptly and allow for the correct information to be communicated, Nationally it is reported that there are an increasing number of situations in which an application for standard and urgent authorisation for DoLs been made by the Managing Authority but the Supervisory Body has not granted the standard authorisation by the time the urgent authorisation has expired: This situation is not provided for in the legislation or code of practice_ Therefore; there is no straightforward legal solution to the problem_ The Trust is committed to safeguarding children; young people and vulnerable adults and requires all staff and volunteers to share this commitment Greater Manchester West Mental Health NHS Foundation Trust; Trust Headquartera, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. Jne & Cetre EMber Our May the has
Greater Manchester West NHS] Mental Health NHS Foundation Trust Staff completing applications will be asked to consider the following if this situation arises again; Apply to extend the urgent authorisation The Head of Operations will write to the Supervisory Body to ask them to set out their reasons for the and also enter into discussion at a senior level to resolve the situation; As patients' needs change frequently further consideration will be given to whether it is appropriate to use the Mental Health Act as the least restrictive option: Similarly; the patients care plan will be reviewed to establish if aspects of the care plan can be amended to make them less onerous and, therefore less likely to amount to a deprivation of liberty: The patient will be referred for an Independent Mental Capacity Advocate (IMCA) with the possibility of them engaging a solicitor to ensure that the patient s rights are safeguarded. You also note that the decision to apply for a DoLs was initially made at & time when the decision was for Mr Bennett to be moved to nursing home care_ Indeed, the evidence provided by the family was that a DoLs application was necessary s0 that he could be moved to the nursing home: There appears to be a lack of understanding as to the fact that DoLs are place specific can confirm that in order to ensure all staff have an increased knowledge about DoLs the staff group have been asked to complete a DoLs training package which includes this information; The completion of this training is mandatory and will be monitored by the ward manager: The additional bespoke training being delivered to senior clinicians will also include this information; If a DoLs is undertaken in the future, an explanatory leaflet will be given to the patients family to reaffirm any verbal explanations that have been given. It can often be a difficult time for families and carers and it is hoped that by giving supportive information it may help families better understand the reasons why a DoLs is being applied for, the parameters of this as well as informing them of the patient's rights Finally; you note Mr Bennett was then on the end stage palliative care and entirely compliant with treatment; there was little consideration as to why a DoLs was applied for as opposed to treating the deceased in his best interests_ The decision to place the patient on DoLs rather than act in his best interests whilst initially appears incorrect; has been reviewed by the Trust Social Care lead and the Directorate Social Care Lead and is considered to be available to the clinicians providing care and treatment in this particular case. The Deprivation of Liberty safeguards provides a legal framework to deprive someone of their liberty whether they are making attempts to leave or not and does not have capacity to make an informed decision (Mental Health Act 1983 Code of Practice 13.45). The Trust's Clinical Improvement Lead Nurse for Dementia, Older People and Carers Services is currently undertaking a review of end of life care. She has been asked to build into the review consideration of the most appropriate legal framework t0 use_ The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment. Greater Manchester West Mental Health NHS Foundation Trust; Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. Nane + % Care Fitm E# delay will
Greater Manchester West NNHS] Mental Health NHS Foundation Trust this response provides assurance to you and Mr Bennets family that GMW have taken the learning from the inquest seriously and have in place measures to ensure safe and effective services_
Greater Manchester West [NHS] Mental Health NHS Foundation Trust Trust Management Offices 18t Floor; The Curve Bury New Road Prestwich Manchester M25 3BL Ref:BHIkearsley19.05.16 Tel: 0161 3581602 23 6y 70.5 19th 2016 Hc Web: WWwgmw nhs.uk WE ARE SOCIAL Miss Kearsley YoufTube Manchester South Coroner's Court Mount Tabor Street Stockport SK1 3AG Dear Miss Kearsley Re: Regulation 28: Dennis Bennett (Deceased) am responding to Regulation 28 you issued to the Trust on 11th April 2016. Whilst Mr Bennett's death was expected on the ward and the concerns you raise are not related to his death; or his care; or treatment;, you note that there is a concern that a lack of understanding and differing information about the Deprivation of Liberty (DoLs) process may and could impact on other patients. For ease will answer each concern separately. You note that the Trust staff completed an application for an urgent DoLs at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act The use of DoLs is rare within the Moorside Unit and Bollin/Greenway Ward. In order to ensure staff have a good understanding of the DoLs process and its relationship to the Mental Health Act senior clinical staff will be provided with further bespoke training about DoLs which will incorporate the concerns you raise. A further concern was raised that there was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. In order to avoid any further miscommunications and because the use of DoLs o the Moorside Unit is rare the Mental Health Act Administrator has been asked to ensure summary email is sent to the Council when iaking advice. This wili ensure any miscommunications are picked up by either party promptly and allow for the correct information to be communicated, Nationally it is reported that there are an increasing number of situations in which an application for standard and urgent authorisation for DoLs been made by the Managing Authority but the Supervisory Body has not granted the standard authorisation by the time the urgent authorisation has expired: This situation is not provided for in the legislation or code of practice_ Therefore; there is no straightforward legal solution to the problem_ The Trust is committed to safeguarding children; young people and vulnerable adults and requires all staff and volunteers to share this commitment Greater Manchester West Mental Health NHS Foundation Trust; Trust Headquartera, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. Jne & Cetre EMber Our May the has
Greater Manchester West NHS] Mental Health NHS Foundation Trust Staff completing applications will be asked to consider the following if this situation arises again; Apply to extend the urgent authorisation The Head of Operations will write to the Supervisory Body to ask them to set out their reasons for the and also enter into discussion at a senior level to resolve the situation; As patients' needs change frequently further consideration will be given to whether it is appropriate to use the Mental Health Act as the least restrictive option: Similarly; the patients care plan will be reviewed to establish if aspects of the care plan can be amended to make them less onerous and, therefore less likely to amount to a deprivation of liberty: The patient will be referred for an Independent Mental Capacity Advocate (IMCA) with the possibility of them engaging a solicitor to ensure that the patient s rights are safeguarded. You also note that the decision to apply for a DoLs was initially made at & time when the decision was for Mr Bennett to be moved to nursing home care_ Indeed, the evidence provided by the family was that a DoLs application was necessary s0 that he could be moved to the nursing home: There appears to be a lack of understanding as to the fact that DoLs are place specific can confirm that in order to ensure all staff have an increased knowledge about DoLs the staff group have been asked to complete a DoLs training package which includes this information; The completion of this training is mandatory and will be monitored by the ward manager: The additional bespoke training being delivered to senior clinicians will also include this information; If a DoLs is undertaken in the future, an explanatory leaflet will be given to the patients family to reaffirm any verbal explanations that have been given. It can often be a difficult time for families and carers and it is hoped that by giving supportive information it may help families better understand the reasons why a DoLs is being applied for, the parameters of this as well as informing them of the patient's rights Finally; you note Mr Bennett was then on the end stage palliative care and entirely compliant with treatment; there was little consideration as to why a DoLs was applied for as opposed to treating the deceased in his best interests_ The decision to place the patient on DoLs rather than act in his best interests whilst initially appears incorrect; has been reviewed by the Trust Social Care lead and the Directorate Social Care Lead and is considered to be available to the clinicians providing care and treatment in this particular case. The Deprivation of Liberty safeguards provides a legal framework to deprive someone of their liberty whether they are making attempts to leave or not and does not have capacity to make an informed decision (Mental Health Act 1983 Code of Practice 13.45). The Trust's Clinical Improvement Lead Nurse for Dementia, Older People and Carers Services is currently undertaking a review of end of life care. She has been asked to build into the review consideration of the most appropriate legal framework t0 use_ The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment. Greater Manchester West Mental Health NHS Foundation Trust; Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. Nane + % Care Fitm E# delay will
Greater Manchester West NNHS] Mental Health NHS Foundation Trust this response provides assurance to you and Mr Bennets family that GMW have taken the learning from the inquest seriously and have in place measures to ensure safe and effective services_
Sent To
- Greater Manchester West Mental Health NHS Foundation Trust
- Trafford Council
Response Status
Linked responses
1 of 2
56-Day Deadline
7 Jun 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 the 5t April [ concluded the Inquest into the death of Dennis Bennett date of birth 24.07.1939 who died on the 07.02.2016. The cause of death was Ia) Dementia [ recorded a natural causes conclusion. CRRCUMSTANCES OF THE DEATH The Court heard evidence that the deceased had a history of dementia and on the 29t November 2015 was admitted in accordance with Section 2 Mental Health Act to the Moorside Unit under the care of Greater Manchester West Mental Health Trust: (GMW): The deceased was shortly after his admission transferred to Wythenshawe hospital for medical treatment before retured to the Moorside Unit on the 64h January 2016. At this time he was admitted under Section 3 of the Mental Health Act for ongoing treatment for his mental health The treatment plan was initially for him to be well enough to be discharged to nursing home care. However on the of the nursing home assessment his condition deteriorated and he was no longer well enough to be discharged. By the 134 January he was for end stage palliative care and following meeting with the family the plan was that he would remain on ward in the Moorside unit: On the 14uh January the Consultant made a urgent Deprivation of Liberty Safeguarding Application to Trafford Council_ As this was an urgent application being day the application commenced on 144 January. At this time the deceased was in act still detained under S3 of the Mental Act and this was not rescinded until the 15t January 2016. The urgent application expired on the 21" January 2016 at which time GMW contacted Trafford Council as the standard authorisation had not been considered. It was the understanding of GMW (albeit the witness from GMW who had responsibility for safeguarding in the Trust was in fact employed by Trafford Council) that the urgent application continued until the best interest assessments could take place and the deceased despite now on end stage palliative care was subject of DOLS at the time he died. Another employee of Trafford Council provided evidence that when he was asked for advice from the Trust the position of the Council was that there was no DOLS in place following the expiration of the urgent authorisation until such time aS the standard application had been processed. CORONER'S CONCERNS The concerns noted by the Court during the course ofthe Inquest are as follows:
1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act:
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. The decision to apply for a DOLS was initially made at & time when the decision was for him to be moved to nursing home care Indeed the evidence provided by the family was that DOLS application was necessary so that he could be moved to the nursing home: There appears to be a lack of 'understanding aS to the fact that DOLS are place specific. The deceased was then on stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLs was applied for as opposed to treating the deceased in his best interests. Whilst in this case the application did not impact on his care or treatment there is a concern that & lack of understanding and differing information may and could impact on other patients. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE the being being end
You are under a to respond to this report within 56 of the date of this report; namely by TJune 2016 L, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION [have sent & copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mr Bennett: Iam also under a to send the Chief Coroner a copy of your response_ 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: 712.04.2016 Joanne Kearsley Area Coroner Osot days duty explain duty
1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act:
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. The decision to apply for a DOLS was initially made at & time when the decision was for him to be moved to nursing home care Indeed the evidence provided by the family was that DOLS application was necessary so that he could be moved to the nursing home: There appears to be a lack of 'understanding aS to the fact that DOLS are place specific. The deceased was then on stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLs was applied for as opposed to treating the deceased in his best interests. Whilst in this case the application did not impact on his care or treatment there is a concern that & lack of understanding and differing information may and could impact on other patients. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE the being being end
You are under a to respond to this report within 56 of the date of this report; namely by TJune 2016 L, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION [have sent & copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mr Bennett: Iam also under a to send the Chief Coroner a copy of your response_ 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: 712.04.2016 Joanne Kearsley Area Coroner Osot days duty explain duty
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Inquest Conclusion
1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act:
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. The decision to apply for a DOLS was initially made at & time when the decision was for him to be moved to nursing home care Indeed the evidence provided by the family was that DOLS application was necessary so that he could be moved to the nursing home: There appears to be a lack of 'understanding aS to the fact that DOLS are place specific. The deceased was then on stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLs was applied for as opposed to treating the deceased in his best interests. Whilst in this case the application did not impact on his care or treatment there is a concern that & lack of understanding and differing information may and could impact on other patients. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE the being being end
You are under a to respond to this report within 56 of the date of this report; namely by TJune 2016 L, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION [have sent & copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mr Bennett: Iam also under a to send the Chief Coroner a copy of your response_ 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: 712.04.2016 Joanne Kearsley Area Coroner Osot days duty explain duty
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. The decision to apply for a DOLS was initially made at & time when the decision was for him to be moved to nursing home care Indeed the evidence provided by the family was that DOLS application was necessary so that he could be moved to the nursing home: There appears to be a lack of 'understanding aS to the fact that DOLS are place specific. The deceased was then on stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLs was applied for as opposed to treating the deceased in his best interests. Whilst in this case the application did not impact on his care or treatment there is a concern that & lack of understanding and differing information may and could impact on other patients. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE the being being end
You are under a to respond to this report within 56 of the date of this report; namely by TJune 2016 L, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION [have sent & copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mr Bennett: Iam also under a to send the Chief Coroner a copy of your response_ 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: 712.04.2016 Joanne Kearsley Area Coroner Osot days duty explain duty
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