Rebecca Claire Pykett · Prevention of Future Deaths report

On 29/07/2019 I commenced an investigation into the death of Rebecca Claire Pykett, aged 39. The investigation concluded at the end of the inquest on 8th July 2021. The conclusion of the inquest was Rebecca Claire Pykett passed away at her home address of ████████ Congleton Road, Talke, Stoke-on-Trent on the 25 February 2019. She passed away after she intentionally hung herself using a tie, that she had fashioned into a ligature and attached to the bedpost, in the bedroom, of her home address. The Medical Cause of death was recorded as follows:

1a) Asphyxiation
1b) Hanging

Rebecca Pykett had a history of mental health difficulties which included a diagnosis of PTSD. These issues became more prominent in October of 2018. This led to three informal inpatients stays in the Harolands Hospital:

1. 10.11.18 – 12.11.18
2. 12.12.18 – 16.12.18
3. 15.01.19 – 18.01.19

She also had periods where she was under the care of the Trust’s Home Treatment:

1. 12.11.18 – 12.12.18
2. 15.01.19 – 21.01.19
3. 03.02.19 – 06.02.19

She was found deceased, having ligatures with a tie in the bedroom of her home address on the 25 February 2019. She was due to attend a medication review with Dr ████████ (a Consultant Psychiatrist) that day, but did not attend.

(1) During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive.

(2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role. What was taking place was that a clinician was being chosen, in Rebecca Pyketts case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator.

(3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pyketts’ case.

(4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-ordinator. The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the Care Co-Ordinator was being dealt with as a “box ticking” exercise, to satisfy the record keeping system.

(5) Once allocated, in this way, it ws clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator.