9 Oct 2023 Mark Anthony McKessy · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of recognition of the interrelationship between health, social care, learning disability and capacity needs View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mark Anthony McKessy · Prevention of Future Deaths report
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Report summary
Mark Anthony McKessy had learning disabilities and care needs and developed alcoholic liver disease following regular and prolonged alcohol use. He deteriorated after admission to Stepping Hill Hospital and died there on 18 February 2023. The principal concerns were poor communication and information sharing between agencies, lack of coordinated care, and insufficient recognition of how his health, social care and learning disability needs interacted, including the extent of his capacity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of recognition of the interrelationship between health, social care, learning disability and capacity needs
Wider context from the report “The inquest heard evidence that he had significant leaning difficulties and his capacity was limited. He was known to agencies. Despite this the inquest heard evidence that steps to reduce the risks were not taken due to:
1. Poor communication/information sharing between agencies which meant that there was no coordination of care and no clear overview of his needs; and
2. A lack of recognition by agencies involved with him of his health issues and their inter relationship with his social care and learning disability needs including the extent to which he had capacity . This was compounded by limited Care Act assessments
” Source location Mark Anthony McKessy · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce peer discussions so managers oversee individual social-care assessments and reviews and strengthen social-work practice.
Verbatim wording from the response “We continue to improve front line practice to ensure our frontline teams increase their knowledge and confidence in completing holistic assessments. To ensure management oversee individual assessments and reviews we are introducing peer discussions to strengthen social work practice. The social care and specialist learning disability health team are co-located to support a joined-up approach to interventions. This is further supported by managers across social care and health meeting on a weekly basis, using the forum to refer individuals for a multi-disciplinary and multi-agency approach.” Source location Response from Stockport Integrated Care Partnership
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31 Oct 2014 CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to identify and act on high-risk patient needs View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
South London and Maudsley NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
South London and Maudsley NHS Foundation Trust
Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.
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South London and Maudsley NHS Foundation Trust
Develop an ICT portal enabling mutual access to key clinical information across Trust and acute electronic patient-record systems.
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South London and Maudsley NHS Foundation Trust
Identify and support community multidisciplinary-team staff to lead physical-health assessment, treatment and patient support.
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South London and Maudsley NHS Foundation Trust
Prioritise community physical-health support in the next CQUIN commissioning round and consider primary-care outreach pilots.
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South London and Maudsley NHS Foundation Trust
Discuss scaling the diabetic liaison service for patients with severe mental-health disorders and develop additional community mental-health staff training.
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South London and Maudsley NHS Foundation Trust
Work with partners to secure community district-nurse provision for safe diabetes management.
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CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify and act on high-risk patient needs
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” Source location CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.
Verbatim wording from the response “• The community team involved have undertaken two specific audits: (a) Team 7 day follow-up performance (Oct-Dec 2014) showed no missed reviews; (b) Discharge of two patients with unstable diabetes (Dec 2014) demonstrated extensive communication and forward planning prior to discharge, appropriately involving all partners.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an ICT portal enabling mutual access to key clinical information across Trust and acute electronic patient-record systems.
Verbatim wording from the response “• ICT harmony: there have been significant developments in increasing mutual access between the Trust and Acute electronic patient record systems, with the development of an ICT ‘Portal’ to review key clinical information; further developments are underway to link these secondary care systems with Primary care ICT (EMIS) systems; this work is further being supported by the Southwark CCG.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify and support community multidisciplinary-team staff to lead physical-health assessment, treatment and patient support.
Verbatim wording from the response “• MDT Physical Health leads within community MDTs: teams are being encouraged to identify and support individual team staff members to lead on developing support for patients to engage with the assessment, treatment and support around their physical health.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise community physical-health support in the next CQUIN commissioning round and consider primary-care outreach pilots.
Verbatim wording from the response “• Commissioning intentions (2015/16): appropriately supporting community patients to manage their physical health are being prioritised in the next round of CQUINs; there is a range of collaborative initiatives including consideration of pilots with GPs undertaking outreach clinics in community team bases to increase the numbers of patients receiving appropriate physical health assessments, investigations and interventions.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss scaling the diabetic liaison service for patients with severe mental-health disorders and develop additional community mental-health staff training.
Verbatim wording from the response “• Southwark Diabetic services; discussions are underway to scale up the award winning Diabetic Liaison service currently running at KCH to assist patients with severe mental health disorders, with additional training being developed for community mental health staff.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with partners to secure community district-nurse provision for safe diabetes management.
Verbatim wording from the response “• Community District Nurses: the Trust is working with our partners to ensure District Nurse provision to ensure safe community diabetes management.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.