This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 29/07/2021 10:54am investigation was commenced into the death of Nicholas James STOUT 31/08/1985 00:00:00. The investigation concluded at the end of the inquest on 09/06/2023 00:00:00. The conclusion of the inquest was that Nicholas 'Nicky' Stout died on 26th July 2021 at Darlington Memorial Hospital due to acute cocaine toxicity and contributed to by coronary artery atheroma. Nicky had mental health issues and was receiving professional support. Nicky was diagnosed with cocaine dependency in 2015. On 26th July 2021 he consumed a large quantity of cocaine. Following symptoms of chest pains his behaviour became increasingly erratic, consistent with acute behavioural disturbance. Despite appropriate interventions from the police and ambulance services, Nicky went into cardiac arrest and subsequently died..
Circumstances of the death
Nicholas 'Nicky' Stout died on 26th July 2021 at Darlington Memorial Hospital due to acute cocaine toxicity and contributed to by coronary artery atheroma. Nicky had mental health issues and was receiving professional support. Nicky was diagnosed with cocaine dependency in 2015. On 26th July 2021 he consumed a large quantity of cocaine. Following symptoms of chest pains his behaviour became increasingly erratic, consistent with acute behavioural disturbance. Despite appropriate interventions from the police and ambulance services, Nicky went into cardiac arrest and subsequently died.
Coroner’s concerns
1. The nationally set time from initial contact with the Crisis Team to some form of assessment is 4 hours. I heard evidence that achievement of this target in every case is not realised. It is of concern that timely assessment and treatment of person undergoing a mental health crisis should be assessed as speedily as possible and within the set time period.
2. The Triage Tool was explained in evidence to be essential in ensuring the patient received the correct treatment/service and is to be undertaken every time a patient contacts the Crisis Team. I was informed there was an aspiration to achieve a completion of the Triage Tool every time, but it is not being completed on every occasion. It is of concern that such a key document which identifies risk, care and other matters is not completed on every occasion as it is mandated to be done. 3. In relation to making safeguarding referrals for children, the evidence I heard was in this particular case a referral should have been made and was not. I was told training had been undertaken to make all staff aware of what action to take. However, I was told in the majority of occasions it was believed a referral would be made. It is of concern in terms of protecting children that I was not satisfied that a referral was made in all situations that warranted such a referral. 4. I was told in evidence that a Safety Plan which is complied with input from the patient, their families and practitioners did not exist in Mr STOUT's case. I was told it is crucial document for identifying risks and ways to mitigate them. I was also told work was commenced by your organisation in December 2020 to ensure full and complete compliance with this requirement, but I was not reassured there was such compliance with the completion of Safety Plans in all cases at this time.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised4
Failure to make safeguarding referrals for children in all warranted situations
Failure to complete timely mental health crisis assessment within the set time period
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.29
Action
Conduct monthly QA5 audits of safety-summary and safety-plan quality, risk mitigation documentation, and completion, with corrective action and clinical supervision.
Stated byThe TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Allocate safeguarding duty workers to provide immediate advice and support during core working hours.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Embed the national triage tool through practitioner induction, staff education, and trained senior-practitioner completion of triages.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Implement monthly caseload-management supervision supported by an electronic caseload dashboard and review of essential care documents.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Use an escalation procedure to obtain senior-management intervention and deploy staff or managers when crisis assessments risk breaching timescales.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Allocate safeguarding-team links to clinical areas to provide safeguarding support and guidance.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Deliver additional training on completing safety summaries and safety plans to crisis staff.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Discuss safeguarding concerns daily in community and crisis huddles, assign actions, and share incident learning and review findings with teams.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Check and discuss every patient’s safety summary and safety plan during daily Crisis Team huddles, assigning required updates.
Stated byThe TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Audit triage-tool use and documentation monthly through QA5 and review compliance in clinical supervision and quality-assurance processes.
Stated byThe TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Provide regular bespoke safety-summary and safety-plan training, including training for new team members.
Stated byThe TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Provide additional training on the Parental Mental Ill Health and Children tool to support safeguarding-referral decisions.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Enhance QA5 auditing to assess PAMIC completion, safeguarding identification, and completion of appropriate safeguarding actions.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Review crisis-service staffing daily, attend safe-staffing meetings, and identify alternative resources during increased acuity.
Stated byThe TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Monitor urgent-referral response compliance through weekly reporting, governance review, monthly specialty reporting, and Care Group escalation.
Stated byThe TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Introduce an escalation procedure requiring delayed-assessment concerns to be discussed with senior management and resourced through redeployment or management clinical support.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Provide additional training for crisis staff on completing safety summaries and safety plans.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Make safeguarding concerns a daily community and crisis-huddle agenda item, assign resulting actions and share incident learning with teams.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Induct current and new crisis-team practitioners in crisis processes, triage-tool use and the rationale for senior-practitioner triage.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Expand QA5 audits to review PAMIC completion, safeguarding identification and completion of appropriate safeguarding actions.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Allocate safeguarding duty workers to provide immediate advice and support during core working hours.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Apply the national triage tool to new or otherwise eligible crisis-service patients and develop interim safety plans with patients and carers.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Check and discuss every patient’s safety summary and safety plan during daily Crisis Team huddles, assigning staff to complete required updates.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Conduct monthly QA5 audits of safety-summary and safety-plan quality, risk mitigation documentation and completion, with corrective action and clinical supervision where needed.
Stated byTees, Esk and Wear Valleys NHS FTStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Deliver regular bespoke safety-summary and safety-plan training, including training during induction for new team staff.
Stated byTees, Esk and Wear Valleys NHS FTStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Audit crisis-team triage-tool completion and quality monthly through QA5 and reinforce compliance through clinician supervision.
Stated byTees, Esk and Wear Valleys NHS FTStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Review crisis-service staffing daily, attend safe-staffing meetings and arrange alternative staffing support when demand threatens timely assessments.
Stated byTees, Esk and Wear Valleys NHS FTStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Provide additional staff training on the PAMIC tool to support recognition and referral of safeguarding concerns affecting children.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Assign safeguarding-team links to clinical areas to provide teams with additional safeguarding support and guidance.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1
Position
Immediate emergency responses are requested through 999 emergency services in line with national guidance.
Stated byTees, Esk and Wear Valleys NHS FTRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6
1
Arrange for crisis clinicians to attend Connecting with People suicide-awareness training.
Stated byThe TrustStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
2
Issue and disseminate a Patient Safety Briefing communicating safeguarding learning across the organisation.
Stated byThe TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
3
Implement monthly caseload-management supervision and an electronic caseload dashboard to identify supervision needs and review essential care documents.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
4
Issue and disseminate a Patient Safety Briefing on the incident’s safeguarding learning across the organisation.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
5
Report and govern very-urgent referral response compliance through weekly monitoring, monthly specialty governance reporting and Care Group escalation.
Stated byTees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
6
Arrange for crisis clinicians to attend Connecting with People suicide-awareness training.
Stated byTees, Esk and Wear Valleys NHS FTStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3
1
The crisis service cannot provide emergency responses because it is not commissioned or resourced and clinicians lack appropriate skills or legal frameworks.
Stated byThe TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
2
Immediate responses to imminent safety or wellbeing concerns should be requested through 999 emergency services.
Stated byThe TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
3
The crisis service cannot provide emergency responses because it is not commissioned or resourced, and lacks appropriate skills and, often, legal authority.
Stated byTees, Esk and Wear Valleys NHS FTUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Information checked against the published report and official responses