Download Concerns Raised in Inquest Report on Mental Health Services & Social Care in Discharge Pla and more Study notes History in PDF only on Docsity!
I
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Gillian Keegan MP
Minister of State (Minister for Care and Mental Health)
Department of Health & Social Care
1 CORONER
I am Alan Anthony Wilson Senior Coroner for Blackpool & Fylde
2 CORONER'S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. httQ:LLwww.legislation .gov.ukLukQgaL2009L25Lschedu1eL5LQaragraQhL htt Q:LL www.le gislation.gov.ukLuksiL2013L1629 Li:1 art L7Lmade
3 INVESTIGATION and INQUEST
The deaths of Marshall Metcalfe on 07 /05/20 and of Jane Ireland on 07 /06/20 were reported to me and I opened investigations on 09/12/20, which concluded by way of an inquest held between 15/11/21 and 25/11/21.
I determined that the medical cause of Marshall's death was: la Multiple injuries, due to
I determined that the medical cause of Jane's death was: I
2 Bronchopneumonia
The conclusion of the Coroner was that Marshall died due to.
The conclusion of the Coroner in Jane's inquest was a Narrative conclusion which reads as follows: At a time when she was grieving following the death of her Son, Jane Ireland died after she
I
in combination with fatty liver disease, proved fatal.
4 CIRCUMSTANCES OF THE DEATH
In box 3 of the Record of Inquest for Marshall, I recorded as follows:
Marshall Metcalfe was known to mental health services. He had twice been admitted to a Tier 4 (Inpatient) Child & Adolescent Mental Health facility, most recently in February 2019 after an apparent relapse of his illness, complicated by physical health difficulties that had required a hospital admission. He had been diagnosed as suffering from psychosis. Marshall was known to be someone who would refuse to engage in almost any social interaction. He
5
was discharged on 06/01/20 and he returned to reside with his Mother. This was a decision clearly made with the support of Marshall and his Mother. By the time he was discharged minimal progress had been made and his lack of engagement persisted. An alternative placement was not considered, largely because of his desire to return home and to a supportive family. Children's social care were unable to contribute to discharge planning having not been notified about Marshall's discharge for approximately two months afterwards. No risk assessment had been completed. Following discharge, Marshall continued to take his prescribed Clozapine medication. Over subsequent weeks his presentation remained stable although his weight did noticeably increase which is a known side effect of that medication. Following discharge, he was not seen by a community psychiatrist at a planned review on 19/03/20 as a result of coronavirus restrictions in place at that time. At around 12 noon on 07 /05/20 he was seen to leave home.
Marshall was transferred by ambulance to the Royal Preston Hospital but had received catastrophic injuries and his death was verified at 14:33 hours that afternoon.
In box 3 of the Record of Inquest for Jane, I recorded as follows:
Jane Ireland was known to have had a history of mental health issues, although in recent years she had been largely stable, and save for a relapse in early 2019 when she had stopped taking her medication and in December 2019 when she went to see her own GP and was referred to START, she experienced no major relapses or acute episodes. On 7th May 2020, Jane's seventeen year old Son died. Having been seen at her home address on 6th^ June 2020 when she is reported to have been in good spirits, Jane was found deceased in her bed by a friend at her home address on 07/06/2020. A paramedic attended and verified her death at 16:00 hours. A subsequent post mortem examination revealed that Jane had, during the hours prior to her death, the toxic effects of which, in combination with fatty liver disease, proved fatal. Her death was more than minimally contributed to by bronchopneumonia identified at post mortem. From the available evidence it cannot be established whether Jane intended to end her life.
CORONER'S CONCERNS
During the course of the inquests, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. -
This report relates to two inquests. They were held jointly after I acceded to a request from the bereaved family that the inquests be conducted together.
As will have been noted from section 4 above, both Marshall Metcalfe and his Mother, Jane Ireland, were known to mental health services. The concern I wish to raise emanated from Marshall's death. He had been admitted to a mental health facility in February 2019 and remained there until he was discharged on 06/01/20 to his Mother's home where he resided until his death on 07/05/20. One month later, his Mother Jane died at her home on 07/06/2020.
8
9
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 21st January 2022. I, 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 explain why no action is proposed.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
- [Sister of Marshall/ Daughter of Jane];
- Lancashire & South Cumbria NHS Foundation Trust;
- Lancashire County Council;
- Blackpool Clinical Commission Group/ Fylde & Wyre Clinical Commissioning Group
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete, 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.
25/11/
Signature _______ __ _ _ Alan Anthony Wilson Senior Coroner Blackpool & Fylde
