Elsie Tindle
PFD Report
All Responded
Ref: 2016-0098
All 1 response received
· Deadline: 3 May 2016
Coroner's Concerns (AI summary)
The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking the bypass of crucial safeguards and inappropriate treatment.
View full coroner's concerns
In the circumstances it is my statutory to report to you_ _ (1) Theard evidence that the present compliment of SOADs is approximately 105 and that in 2014/15 carried out 14,373 visits. 25% of cases with a SOAD led to changes in a treatment plan and in 3% of cases the SOAD did not approve the plan. The SOAD safeguard in theory can prevent the inappropriate use Of ECT.
(2) For ECT, SOADs attend within 5 days in 82% of cases but am concerned that in 1.5 cases this does not happen.
(3) Practitioners anticipate delays with the appointment of SOADs and it is common to use the urgent powers under 562 MHA (it is immediately necessary to save the patient' $ life or prevent a serious deterioration in their condition)_ (4) Tam concerned that there is a danger of the use of s62 MHA becoming a default position and that the numbers of SOADs may be insufficient to deal with matters in a more timely way_ (5) was encouraged to hear that each of the had reviewed practices and procedures, particularly Northumberland Tyne and Wear NHS Foundation Trust, who were to set up a system for_the treating Psychiatrist to chase the CQC in the absence of a day 19th 29th duty they agencies timely appointment of a SOAD
(2) For ECT, SOADs attend within 5 days in 82% of cases but am concerned that in 1.5 cases this does not happen.
(3) Practitioners anticipate delays with the appointment of SOADs and it is common to use the urgent powers under 562 MHA (it is immediately necessary to save the patient' $ life or prevent a serious deterioration in their condition)_ (4) Tam concerned that there is a danger of the use of s62 MHA becoming a default position and that the numbers of SOADs may be insufficient to deal with matters in a more timely way_ (5) was encouraged to hear that each of the had reviewed practices and procedures, particularly Northumberland Tyne and Wear NHS Foundation Trust, who were to set up a system for_the treating Psychiatrist to chase the CQC in the absence of a day 19th 29th duty they agencies timely appointment of a SOAD
Responses
Action Taken
The Department of Health acknowledges CQC's administrative error and the SOAD shortage. CQC has undertaken a 100% comparison check and implemented process reminders and daily checks to mitigate errors, and is also reviewing the SOAD fee structure to potentially free up SOAD time. The Department of Health has strengthened the 2015 MHA Code of Practice concerning the use of section 62, and SOADs have been instructed to feedback any issues regarding the use of s62 directly to CQC. (AI summary)
The Department of Health acknowledges CQC's administrative error and the SOAD shortage. CQC has undertaken a 100% comparison check and implemented process reminders and daily checks to mitigate errors, and is also reviewing the SOAD fee structure to potentially free up SOAD time. The Department of Health has strengthened the 2015 MHA Code of Practice concerning the use of section 62, and SOADs have been instructed to feedback any issues regarding the use of s62 directly to CQC. (AI summary)
View full response
Rt Hon Alislair Burt MP Minister of State for Community Social Care Department of Health Richmond House 79 Whitehall London Senior Coroner SWIA 2NS Civic Centre Tel: 020 7210 4850 Burdon Road Sunderland SR2 7DN 9 MAY 2016 (cx Mr Vale Thank you for your letter of & March 2016, following the inquest into the death of Elsie Tindle. I was sorry to hear of her death and wish to extend my condolences to her family. The main concerns arising from this case are: that the Care Quality Commission 's (CQC) internal target for provision of SOADs is not met in all circumstances and the impact this has on safeguarding against inappropriate treatment; that there is an insufficient number of Second Opinion Appointed Doctors (SOADs) to deal with requests for attendance in a timely way; that the use of section 62 of the Mental Health Act (MHA) is becoming a default position. officials have liaised with CQC about your concerns_ Firstly, with regard to CQC's lack of response to the request for a SOAD in this case, Ihave been advised by CQC that this was due to an administrative error: CQC has confirmed that a second opinion request was submitted by Northumberland Tyne and Wear NHS Foundation Trust and received by CQC. Although the request was processed, there was a failure to action it any further by transferring it from the submission system onto the allocation database, which is currently a manual process. Investigation of this error has led to two possible causes: The task completed line was ticked in error_ There was an error on the submission and the request was misplaced before the query was resolved and the process completed: and My
CQC has undertaken a 100% comparison check between the submission database and the allocation database and has confirmed that this was an isolated incident: However; have taken the following actions to mitigate further error: The team have been reminded of the process recording actions taken against requests received; Daily 100% comparison checks are now carried out by the team leader; requests submitted with queries are entered onto the allocation database with a status of pending: The team leader keeps checking the progress of pending second opinion requests until all issues are resolved; An electronic solution to enable automatic transfer of request to the allocation database is in the final stage of roll out. This will reduce the risk of human error in future. You are also concerned that CQC do not always meet their internal target for provision of SOADs Whilst CQC fully endeavour to meet these targets, there are several factors that can affect their ability to do so. Requests for Second Opinions are demand led. CQC has no control over when and where a request will be required or the level ofurgency required for each case. In addition, as most SOADS are in full or part time employment with provider organisations, it can be difficult to identify a local, available SOAD who can attend promptly: As a second treatment of the patient is often carried out within 48 hours of the request submitted it makes timely attendance of a SOAD even more challenging: Missing Or inaccurate request information submitted by the provider can add in further delay: In addition, providers do not always make appropriate arrangements to enable the SOAD to attend the ward, interview the patient and have access to the statutory consultees either in person or at least via telephone, s0 that a certificate can be issued. Another problem; although less common; is when a SOAD is unable to access a ward due to protected times To turn to your concern about the available number of SOADs, CQC has an ongoing recruitment campaign and invites expressions of interest from prospective applicants. Their recruitment process is supported by HR colleagues and the Lead SOAD. CQC will continue to recruit more Consultants as SOADS but because the work is sO demand led, a model of continuous availability is not considered feasible It is also essential to continue to ensure that the SOAD is independent of the provider and other parties. they against for Any being
Department of Health CQC continues to work with the Royal College of Psychiatrists to promote the value ofthe SOAD role and its importance to the provision of comprehensive mental healthcare. They are also considering other ways of promoting the SOAD role including reviewing the current fee structure and are looking at providing some aspects of the service in a different way that could free up more SOAD time Lastly, I will address your concer that the use of s62 of the MHA is becoming a default position. S62 of the MHA provides provision to urgently treat a person who has been detained under the MHA . Sometimes, decisions have to be taken rapidly to detain and then treat a deteriorating patient and this should be clearly understood by the s62 provision of the Act: CQC has raised concerns about the use of s62, (separate from the issue of SOAD availability), which highlighted in their MHA Monitoring Annual Report for 2013/14. are concerned that these measures are being used in situations that are neither urgent nor emergency. They also perceive that there are occasions when 562 may be used, whether for medication or for ECT, for the purpose of clinical convenience rather than a situation of immediate necessity: As a consequence of these concerns the 2015 MHA Code of Practice has been strengthened to state that hospital managers should monitor both the use of urgent treatments and exceptions to the certificate requirements, to make sure that are not used inappropriately or excessively. CQC also expect providers to make sure that treatments given on this basis are reviewed regularly. Clinicians must specify review periods at the that the urgent or emergency treatment is instigated. CQC Inspectors and Mental Health Act Reviewers continue to look at compliance with the MHA Code of Practice during inspections and MHA monitoring visits. In addition SOADs have been instructed to feedback any issues regarding the use of s62 which may encounter on their visits, directly to CQC, s0 that targeted intervention can be addressed to relevant providers as necessary: I hope that this reply is helpful and I am grateful to you for bringing the circumstances of Ms Tindle's death to my attention. Juc Tnucs
3.n ALISTAIR BURT they They they point they Oe
CQC has undertaken a 100% comparison check between the submission database and the allocation database and has confirmed that this was an isolated incident: However; have taken the following actions to mitigate further error: The team have been reminded of the process recording actions taken against requests received; Daily 100% comparison checks are now carried out by the team leader; requests submitted with queries are entered onto the allocation database with a status of pending: The team leader keeps checking the progress of pending second opinion requests until all issues are resolved; An electronic solution to enable automatic transfer of request to the allocation database is in the final stage of roll out. This will reduce the risk of human error in future. You are also concerned that CQC do not always meet their internal target for provision of SOADs Whilst CQC fully endeavour to meet these targets, there are several factors that can affect their ability to do so. Requests for Second Opinions are demand led. CQC has no control over when and where a request will be required or the level ofurgency required for each case. In addition, as most SOADS are in full or part time employment with provider organisations, it can be difficult to identify a local, available SOAD who can attend promptly: As a second treatment of the patient is often carried out within 48 hours of the request submitted it makes timely attendance of a SOAD even more challenging: Missing Or inaccurate request information submitted by the provider can add in further delay: In addition, providers do not always make appropriate arrangements to enable the SOAD to attend the ward, interview the patient and have access to the statutory consultees either in person or at least via telephone, s0 that a certificate can be issued. Another problem; although less common; is when a SOAD is unable to access a ward due to protected times To turn to your concern about the available number of SOADs, CQC has an ongoing recruitment campaign and invites expressions of interest from prospective applicants. Their recruitment process is supported by HR colleagues and the Lead SOAD. CQC will continue to recruit more Consultants as SOADS but because the work is sO demand led, a model of continuous availability is not considered feasible It is also essential to continue to ensure that the SOAD is independent of the provider and other parties. they against for Any being
Department of Health CQC continues to work with the Royal College of Psychiatrists to promote the value ofthe SOAD role and its importance to the provision of comprehensive mental healthcare. They are also considering other ways of promoting the SOAD role including reviewing the current fee structure and are looking at providing some aspects of the service in a different way that could free up more SOAD time Lastly, I will address your concer that the use of s62 of the MHA is becoming a default position. S62 of the MHA provides provision to urgently treat a person who has been detained under the MHA . Sometimes, decisions have to be taken rapidly to detain and then treat a deteriorating patient and this should be clearly understood by the s62 provision of the Act: CQC has raised concerns about the use of s62, (separate from the issue of SOAD availability), which highlighted in their MHA Monitoring Annual Report for 2013/14. are concerned that these measures are being used in situations that are neither urgent nor emergency. They also perceive that there are occasions when 562 may be used, whether for medication or for ECT, for the purpose of clinical convenience rather than a situation of immediate necessity: As a consequence of these concerns the 2015 MHA Code of Practice has been strengthened to state that hospital managers should monitor both the use of urgent treatments and exceptions to the certificate requirements, to make sure that are not used inappropriately or excessively. CQC also expect providers to make sure that treatments given on this basis are reviewed regularly. Clinicians must specify review periods at the that the urgent or emergency treatment is instigated. CQC Inspectors and Mental Health Act Reviewers continue to look at compliance with the MHA Code of Practice during inspections and MHA monitoring visits. In addition SOADs have been instructed to feedback any issues regarding the use of s62 which may encounter on their visits, directly to CQC, s0 that targeted intervention can be addressed to relevant providers as necessary: I hope that this reply is helpful and I am grateful to you for bringing the circumstances of Ms Tindle's death to my attention. Juc Tnucs
3.n ALISTAIR BURT they They they point they Oe
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
3 May 2016
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 4th April 2015 [ commenced an Investigation into the death of Elsie Tindle; years_ The investigation concluded at the end of the Inquest on 3rd March 2016. The conclusion of the Inquest was that she died as a result of a rare complication following the lawful and necessary administration of ECT'
Circumstances of the Death
Elsie Tindle had a complex personal and medical history. Miss Tindle was particularly close to her sister with whom she had lived. Miss Tindle had a psychiatrie diagnosis of Depressive Disorder of a severe degree with a suspected underlying cognitive impairment and a learning disability: On February 2015 Miss Tindle was made subject to section 3 of the Mental Health Act 1983 (MHA). Miss Tindle received Electro Convulsive Therapy (ECT) on February 2015,6th March 2015 and 9uh March 2015. On 23" February 2015,a paper request for a Second Opinion Appointed Doctor SOAD) was made to the Care Quality Commission (CQC) and then subsequently online to the CQC, who acknowledged it the following Civic Centre; Burdon Road,Sunderland, SRZ 7DN Tel 0191 5617843 Fax 0[9[ 5537803 DX 60729 Sunderland Www.sunderland gov uklcoroner City aged Jury 23rd 27th day_
It appears that no SOAD was ever allocated and that the request was not followed up. Miss Tindle had 3 sessions 0f ECT over an 11 period as it was believed that the s62 MHA criteria had been made out in that it was immediately necessary to save the patient' s life O prevent a serious deterioration in her condition Miss Tindle was removed from the section 3 on [th March 2015. Miss Tindle developed focal seizures and status epilepticus, which required her transfer to the High Dependency Unit of Sunderland Royal Hospital, and she was then discharged back to the ward at the Hospital on 16h March 2015. On March 2015 Miss Tindle was made subject to a Deprivation of Liberty Safeguard. By March 2015 Miss Tindle appeared to develop aspiration pneumonia and, although she was treated with antibiotics, her decline continued and she died on 4th April 2015. Post-Mortem Examination on 14"h April 2015 gave the cause of death for Miss Tindle as: Ia Anoxic-Ischaemic Brain Damage Due to 1b Status Epilepticus Due to le Electro-Convulsive Therapy
It appears that no SOAD was ever allocated and that the request was not followed up. Miss Tindle had 3 sessions 0f ECT over an 11 period as it was believed that the s62 MHA criteria had been made out in that it was immediately necessary to save the patient' s life O prevent a serious deterioration in her condition Miss Tindle was removed from the section 3 on [th March 2015. Miss Tindle developed focal seizures and status epilepticus, which required her transfer to the High Dependency Unit of Sunderland Royal Hospital, and she was then discharged back to the ward at the Hospital on 16h March 2015. On March 2015 Miss Tindle was made subject to a Deprivation of Liberty Safeguard. By March 2015 Miss Tindle appeared to develop aspiration pneumonia and, although she was treated with antibiotics, her decline continued and she died on 4th April 2015. Post-Mortem Examination on 14"h April 2015 gave the cause of death for Miss Tindle as: Ia Anoxic-Ischaemic Brain Damage Due to 1b Status Epilepticus Due to le Electro-Convulsive Therapy
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.