Philip Dean
PFD Report
Partially Responded
Ref: 2014-0172
Coroner's Concerns (AI summary)
Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.
View full coroner's concerns
That the HHT is not sufficiently funded to allow continuity of care and named designated workers_ from day, The rise
(2)That discharge from the HTT is required before referral to psychology can be made, leaving patients without ongoing support in the interim.
(3) That Iiaison psychiatry does not record pertinent information such as GP recommends section, this denying those coming after the benefit of the GP's professional opinion.
(4) That such an extremely psychiatrically unwell patient does not have the benefit of assessment from a health care professional qualified to make recommendations for section at first instance, despite explicit referral for the same from the doctor who knows him best.
(5) That secondary care services both the HTT and Liaison Psychiatry appear under to be under-resourced especially in terms of medically qualified personnel, and that this apparent under-resource impacts on the ability of these services to make accurate assessments of patients.
(6) That The SUI report missed all matters in issue in this case
(2)That discharge from the HTT is required before referral to psychology can be made, leaving patients without ongoing support in the interim.
(3) That Iiaison psychiatry does not record pertinent information such as GP recommends section, this denying those coming after the benefit of the GP's professional opinion.
(4) That such an extremely psychiatrically unwell patient does not have the benefit of assessment from a health care professional qualified to make recommendations for section at first instance, despite explicit referral for the same from the doctor who knows him best.
(5) That secondary care services both the HTT and Liaison Psychiatry appear under to be under-resourced especially in terms of medically qualified personnel, and that this apparent under-resource impacts on the ability of these services to make accurate assessments of patients.
(6) That The SUI report missed all matters in issue in this case
Responses
Action Taken
South West London and St George's NHS Trust has revised serious incident procedures so that initial findings from concise investigations are reviewed after ten working days to consider escalating to a comprehensive investigation if necessary. They have commissioned externally led training workshops to develop knowledge, skills and quality assurance processes for investigations and report writing. (AI summary)
South West London and St George's NHS Trust has revised serious incident procedures so that initial findings from concise investigations are reviewed after ten working days to consider escalating to a comprehensive investigation if necessary. They have commissioned externally led training workshops to develop knowledge, skills and quality assurance processes for investigations and report writing. (AI summary)
View full response
Dear Dr Wilcox, am writing in response to the Regulation 28 Report to Prevent Future Deaths and the concerns You_raised following the inquest into the death of Mr Philip Anthony Dean Head of Nursing for Community Services Consultant Psychiatrist and Wandsworth Clinical Director; Associate Director for Psychology and Psychotherapies and Clinical Lead for Wandsworth Psychological Therapies and Wellbeing Service (IAPT) and Serious Incident Lead Investigator have contributed to the response to the six matters of concern in the order raised for ease of reference as follows: 1 That the Home Treatment Team (HTT) is not sufficiently funded to allow continuity of care and named designated workers. The Trust is committed to ensuring continuity of care for service users and although it is not within the Trust's current Operational Policy for HTT's to work with designated workers the policy does state that service users accepted for home treatment; who have been newly referred or re-referred to Mental Health Services and SO do not have an existing Care Coordinator; be temporarily care coordinated within the team, in the context of a whole team approach: Trust Headquarters, Springfield University Hospital, 61 Glenburnie Road, London SW17 7DJ Tel: 020 3513 5000 wwwswlstg-trnhsuk par tnership with Integrated health and social care for local people with mental health problems in Kingston; Merton, Richmond, Sutton and Wandsworth and more specialist mental health services for people throughout the UK St Georges Unlversity of London a_eloaleclre V6/xoa4 key Laec y 200 will
The Mental Health Implementation Guide suggests that HTT's should provide designated named worker, responsible for coordinating service users care, providing continuity of care, ensuring effective communication within the team and acting as a contact point for both service users and Carers Although there are number of practical issues that currently impact on the HTT's ability to operate system of designated workers pilot will be commenced, taking the learning from other HTT's nationally, and reviewed in six months The average length of for a service user in HTT is 2 to 3 weeks and maximum of 6 weeks_ Staff working in HTT's work shift patterns. The designated worker and service users ability to have contact would be dependent on the worker allocated to a shift and day on which the service user is due to be visited. This would mean constantly making changes to the roster to facilitate contact, changing the service users visit time and or days (which are often down to preference), setting minimum number of designated worker visits a week or a mixture of all three options_ However; the Wandsworth HTT has implemented robust processes to aid continuity of care for service users_ There are twice handovers for staff coming on duty: the morning handover all service users who are due a visit in the morning, any patients that are on alternate morning visits who are not due to be seen that day and any issues which have arisen since handover from the previous afternoon shift or night are discussed in detail. During afternoon handover those service users due a visit in the afternoon and service users on alternate day afternoon visits that are not due to be visited that afternoon shift are discussed, The morning shift then handover their visits and make any changes to that afternoon's visit list. This allows each shift access to pertinent information about the service user and reduces the likelihood of information being missed. A zoning system also operates which gives an overall indication of the service users risk and need. In terms of funding the HTT has been identified as being under resourced based on the expected number of contacts for the teams caseload and the number of crisis episodes which are expected to be completed per month: Trust wide Acute Care Pathway Project; undertaken in March 2014 identified that Wandsworth HTT was under established by 3 Whole Time Equivalent (WTE) of nursing staff. Furthermore, the project identified that Wandsworth HTT took over the management of the Trust's Crisis line in approximately 2009 without additional resource being provided equating to 2 additional WTE of nursing staff required. Medical staffing in HTT was not identified as a concern: Nurse understaffing has led to a slight dependence on agency staff in order to cover increases in workload which may have caused some problems with continuity of care and the ability to provide designated workers however HTT has now been allocated E214,000 investment as a result of the Acute Care Pathway Project which will be used to fund the posts required and will increase the nursing establishment to the appropriate level: This will assist considerably in the pilot to introduce designated workers. Recruitment has already begun to the new South West London and St: George's Mental Health NHS Trust stay stay being daily During days
3. That Iiaison psychiatry does not record pertinent information such as GP recommends section, this denying those coming after the benefit of the GP's professional opinion It is expected that the Liaison Psychiatry team do record pertinent information in the electronic patient record and that all documentation from referrers is uploaded and available on this system. It is expected that staff read all relevant documentation when making an assessment: It is with regret that the information from the GP was not passed on appropriately, however risk is a factor that shifts and changes and each assessment will include a new and up to date risk evaluation, based upon the person's current situation: As result of the assessment made, an appropriate decision was taken to admit Mr Dean: As risk can change very rapidly, it is possible that the mental health assessor may come to different conclusion to that recommended by the GP. 4 That such an extremely psychiatrically unwell patient does not have the benefit of assessment from health care professional qualified to make recommendations for section at first instance, despite explicit referral for the same from the doctor who knows him best It has not been possible to identify any Accident and Emergency Department which runs a psychiatry service that has 24 hour 7 a week presence of Section 12 approved doctors and none where the Section 12 doctor would always do the assessment at first instance, unless the patient were being assessed in police cell: Therefore it appears that Mr Dean received the most appropriate assessment available and this is comparable to other psychiatric services available elsewhere. The staff in Liaison Psychiatry are experienced in carrying out mental health assessments and receive extensive training and ongoing supervision: 5 That secondary care services, both the HTT and Liaison Psychiatry, appear to be under-resourced especially in terms of medically qualified personnel and that this apparent under resource impacts on the ability of these services to make accurate assessments of patients The Liaison Psychiatry service is under-resourced compared to national guidance on staffing levels: In this regard, so are the majority of Liaison Psychiatry departments and the under-resourcing is matter primarily for the Trust's commissioners, rather than problem of resource allocation within the Trust. The Trust do have fewer Consultants than most London teaching hospital Liaison Psychiatry departments however the implication that only medically qualified staff can make accurate assessments is not accepted: An experienced and competent Band nurse will do much more robust assessment than a doctor who has been training in psychiatry for a few years and their assessments will be on par with senior doctor's. An example of this was demonstrated last year when a Trust Consultant Psychiatrist provided Coroner with data which showed a low South West London and St: George's Mental Health NHS Trust day very
rate of suicide in patients who were assessed and discharged home by St George's Liaison Psychiatry team, based on Trust data collection;
6. That the Sl report missed all matters in issue in this case As part of the Serious Incident Reporting process, the Trust identifies the level of investigation that is required for each individual serious incident concise investigation is led by one of the Patient Experience Leads from the Quality Governance Department; supported by the Serious Incident Lead Investigator or another experienced clinician The concise investigation reviews the medical records makes contact with the familylrelatives, liaises with the service or teams involved, reviews policy and identifies learning: An internal comprehensive investigation comprises small panel of clinicians led by the Serious Incident Lead Investigator. This is more detailed and comprehensive investigation covering all of the aspects of the concise approach plus specific terms of reference for the incident meetings with familylrelatives, interviews with teams and individual practitioners (including GPs) , benchmarking and access to expert opinion in particular field as required. A comprehensive investigation with an External Chair is initiated following an inpatient death; abscond of a patient from a secure ward; homicide involving patient in receipt of services; any Never Event Having reviewed this investigation and the points raised at Inquest; the Trust has identified that this incident would have benefited from comprehensive rather than a concise investigation. The GP would have been invited to contribute to the Trust investigation and provide an external context and further lines of inquiry: This would have provided information about the GP concerns and these would have been explored in detail, As a Trust we have learnt from this and as a result of a review of our serious incident procedures, initial findings from concise investigations are reviewed after ten working days so that the level of complexity can be considered and the case escalated to the level of comprehensive investigation if necessary: AlI comprehensive investigations are led by an experienced clinician, quality assured by the Serious Incident Lead Investigator; signed off by Board member and agreed with the Clinical Commissioning Groups The Trust has commissioned externally led training workshops to develop knowledge , skills and quality assurance processes for investigations and report writing: Root Cause Analysis investigations may identify issues that are concerning but are deemed not to have a direct bearing on the outcome and are not identified as contributory factor to the incident itself. The concerns identified and highlighted from this Inquest will contribute directly to Trust learning and development with regards to contributions from family and relatives, external agencies and the quality of investigations, report writing and action plans Soulh West London and St. George's Mental Health NHS Trust key
In closing, hope this letter has addressed the concerns you raised. If you would like to discuss any aspect of this letter by telephone; then please do not hesitate to contact me, on
The Mental Health Implementation Guide suggests that HTT's should provide designated named worker, responsible for coordinating service users care, providing continuity of care, ensuring effective communication within the team and acting as a contact point for both service users and Carers Although there are number of practical issues that currently impact on the HTT's ability to operate system of designated workers pilot will be commenced, taking the learning from other HTT's nationally, and reviewed in six months The average length of for a service user in HTT is 2 to 3 weeks and maximum of 6 weeks_ Staff working in HTT's work shift patterns. The designated worker and service users ability to have contact would be dependent on the worker allocated to a shift and day on which the service user is due to be visited. This would mean constantly making changes to the roster to facilitate contact, changing the service users visit time and or days (which are often down to preference), setting minimum number of designated worker visits a week or a mixture of all three options_ However; the Wandsworth HTT has implemented robust processes to aid continuity of care for service users_ There are twice handovers for staff coming on duty: the morning handover all service users who are due a visit in the morning, any patients that are on alternate morning visits who are not due to be seen that day and any issues which have arisen since handover from the previous afternoon shift or night are discussed in detail. During afternoon handover those service users due a visit in the afternoon and service users on alternate day afternoon visits that are not due to be visited that afternoon shift are discussed, The morning shift then handover their visits and make any changes to that afternoon's visit list. This allows each shift access to pertinent information about the service user and reduces the likelihood of information being missed. A zoning system also operates which gives an overall indication of the service users risk and need. In terms of funding the HTT has been identified as being under resourced based on the expected number of contacts for the teams caseload and the number of crisis episodes which are expected to be completed per month: Trust wide Acute Care Pathway Project; undertaken in March 2014 identified that Wandsworth HTT was under established by 3 Whole Time Equivalent (WTE) of nursing staff. Furthermore, the project identified that Wandsworth HTT took over the management of the Trust's Crisis line in approximately 2009 without additional resource being provided equating to 2 additional WTE of nursing staff required. Medical staffing in HTT was not identified as a concern: Nurse understaffing has led to a slight dependence on agency staff in order to cover increases in workload which may have caused some problems with continuity of care and the ability to provide designated workers however HTT has now been allocated E214,000 investment as a result of the Acute Care Pathway Project which will be used to fund the posts required and will increase the nursing establishment to the appropriate level: This will assist considerably in the pilot to introduce designated workers. Recruitment has already begun to the new South West London and St: George's Mental Health NHS Trust stay stay being daily During days
3. That Iiaison psychiatry does not record pertinent information such as GP recommends section, this denying those coming after the benefit of the GP's professional opinion It is expected that the Liaison Psychiatry team do record pertinent information in the electronic patient record and that all documentation from referrers is uploaded and available on this system. It is expected that staff read all relevant documentation when making an assessment: It is with regret that the information from the GP was not passed on appropriately, however risk is a factor that shifts and changes and each assessment will include a new and up to date risk evaluation, based upon the person's current situation: As result of the assessment made, an appropriate decision was taken to admit Mr Dean: As risk can change very rapidly, it is possible that the mental health assessor may come to different conclusion to that recommended by the GP. 4 That such an extremely psychiatrically unwell patient does not have the benefit of assessment from health care professional qualified to make recommendations for section at first instance, despite explicit referral for the same from the doctor who knows him best It has not been possible to identify any Accident and Emergency Department which runs a psychiatry service that has 24 hour 7 a week presence of Section 12 approved doctors and none where the Section 12 doctor would always do the assessment at first instance, unless the patient were being assessed in police cell: Therefore it appears that Mr Dean received the most appropriate assessment available and this is comparable to other psychiatric services available elsewhere. The staff in Liaison Psychiatry are experienced in carrying out mental health assessments and receive extensive training and ongoing supervision: 5 That secondary care services, both the HTT and Liaison Psychiatry, appear to be under-resourced especially in terms of medically qualified personnel and that this apparent under resource impacts on the ability of these services to make accurate assessments of patients The Liaison Psychiatry service is under-resourced compared to national guidance on staffing levels: In this regard, so are the majority of Liaison Psychiatry departments and the under-resourcing is matter primarily for the Trust's commissioners, rather than problem of resource allocation within the Trust. The Trust do have fewer Consultants than most London teaching hospital Liaison Psychiatry departments however the implication that only medically qualified staff can make accurate assessments is not accepted: An experienced and competent Band nurse will do much more robust assessment than a doctor who has been training in psychiatry for a few years and their assessments will be on par with senior doctor's. An example of this was demonstrated last year when a Trust Consultant Psychiatrist provided Coroner with data which showed a low South West London and St: George's Mental Health NHS Trust day very
rate of suicide in patients who were assessed and discharged home by St George's Liaison Psychiatry team, based on Trust data collection;
6. That the Sl report missed all matters in issue in this case As part of the Serious Incident Reporting process, the Trust identifies the level of investigation that is required for each individual serious incident concise investigation is led by one of the Patient Experience Leads from the Quality Governance Department; supported by the Serious Incident Lead Investigator or another experienced clinician The concise investigation reviews the medical records makes contact with the familylrelatives, liaises with the service or teams involved, reviews policy and identifies learning: An internal comprehensive investigation comprises small panel of clinicians led by the Serious Incident Lead Investigator. This is more detailed and comprehensive investigation covering all of the aspects of the concise approach plus specific terms of reference for the incident meetings with familylrelatives, interviews with teams and individual practitioners (including GPs) , benchmarking and access to expert opinion in particular field as required. A comprehensive investigation with an External Chair is initiated following an inpatient death; abscond of a patient from a secure ward; homicide involving patient in receipt of services; any Never Event Having reviewed this investigation and the points raised at Inquest; the Trust has identified that this incident would have benefited from comprehensive rather than a concise investigation. The GP would have been invited to contribute to the Trust investigation and provide an external context and further lines of inquiry: This would have provided information about the GP concerns and these would have been explored in detail, As a Trust we have learnt from this and as a result of a review of our serious incident procedures, initial findings from concise investigations are reviewed after ten working days so that the level of complexity can be considered and the case escalated to the level of comprehensive investigation if necessary: AlI comprehensive investigations are led by an experienced clinician, quality assured by the Serious Incident Lead Investigator; signed off by Board member and agreed with the Clinical Commissioning Groups The Trust has commissioned externally led training workshops to develop knowledge , skills and quality assurance processes for investigations and report writing: Root Cause Analysis investigations may identify issues that are concerning but are deemed not to have a direct bearing on the outcome and are not identified as contributory factor to the incident itself. The concerns identified and highlighted from this Inquest will contribute directly to Trust learning and development with regards to contributions from family and relatives, external agencies and the quality of investigations, report writing and action plans Soulh West London and St. George's Mental Health NHS Trust key
In closing, hope this letter has addressed the concerns you raised. If you would like to discuss any aspect of this letter by telephone; then please do not hesitate to contact me, on
Sent To
- South Wet London and St George’s Mental Health NHS Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
10 Jun 2014
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 16lh August 2013 commenced an investigation into the death of Mr Philip Anthony Dean;_aged 65 years. The investigation concluded at the end of the inquest on gth April 2014. conclusion of the inquest was: Medical Cause of Death (a) Drowning: How; when and where and in what circumstances the deceased came by his death: Mr Philip Dean suffered with chronic depressive illness. From June 2013 until his death, he suffered an exacerbation of this illness and became suicidal. He was referred to the Home Treatment Team and had a short admission to Springfield Trust, Friday The
Hospital between 9/8/2013 and 72/8/2013. On the 13/8/2013, he jumped Battersea bride into the River Thames. He was recovered from the water and resuscitated, but unfortunately could not be saved and was recognised life extinct at Chelsea and Westminster Hospital the same morning: With hindsight his death at this time was potentially predictable and therefore preventable The recognition of his suicidality may have been hampered by the Iack of continuity in the secondary psychiatric care services: Conclusion of the Coroner as to the death He took his own life whilst suffering from depressive illness.
Hospital between 9/8/2013 and 72/8/2013. On the 13/8/2013, he jumped Battersea bride into the River Thames. He was recovered from the water and resuscitated, but unfortunately could not be saved and was recognised life extinct at Chelsea and Westminster Hospital the same morning: With hindsight his death at this time was potentially predictable and therefore preventable The recognition of his suicidality may have been hampered by the Iack of continuity in the secondary psychiatric care services: Conclusion of the Coroner as to the death He took his own life whilst suffering from depressive illness.
Circumstances of the Death
Whilst the HTT was caring for Mr Dean, he only saw the same person on 2 occasions Mr Dean therefore had no opportunity to develop any meaningful therapeutic relationships with the HTT_ This may be why Mr Dean chose not to share suicidal intent with the professional who saw him the evening before he took his own life; based upon information gained from Mr Dean's family. The HTT has no system of designated worker to provide such continuity. Mr Dean had to be discharged from the HTT to allow referral to psychology services, leaving him with only a crisis line number in the interim, but no ongoing planned intervention: His GP was the one NHS health care professional with whom he had ongoing contact and knew him best On 9"h August 2013, his GP arranged for police to attend Mr Dean ad take thim to hospital if necessary under a section 136, since Mr Dean was in a park with aknife and expressing active suicidal intent This was on tOp of on the 6" August describing to his GP a method of suicide in his contemplation that turned out to behow he took his life. On the same day, Mr Dean expressed no ideation to the HTT: On 9" August his GP also telephoned psychiatric Iiaison at St Georges and stated that in his View Mr Dean should be assessed for section: This was not recorded in his notes and further Mr Dean was not seen by anyone who could have performed such an assessment Neither was this information passed to the psychiatrist who subsequently allowed him to go home on the 12/h August 2013, who thus made this decision without the benefit of the opinion of the GP_ Mr Dean had not seen by a doctor until the following despite the circumstances of his admission and then onily by a junior SHO, Who had no prior knowledge of Mr Dean and no access to the GP's concerns The SHO records in the note that his assessment was limited to clerking essentials only due to pressure of work. SUI into this death did not demonstrate insight into any of the pertinent issues and was thus inadequate and unhelpful
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: It is for each person or organisation to whom or which this report is addressed to identify and respond to the matters pertinent to their area of work:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.