Patricia Ferguson · Prevention of Future Deaths report

An inquest was opened into the death of Patricia Ferguson on the 9th May 2019 and concluded on the 15th August 2019. The conclusion of the inquest was that the death was suicide. Prior to the death Patricia Ferguson had been in receipt of secondary mental health services from her local Community Mental Health Team. The care afforded by the clinicians working with Patricia Ferguson was good. The psychiatrist and community psychiatric nurse working with Patricia Ferguson formed the clinical view that she would benefit from direct work from a clinical psychologist. A clinical psychologist was not, however, available to carry out direct work.

Patricia Ferguson suffered significant mental ill health at times. She was admitted as an inpatient on one occasion and on other occasions she received secondary mental healthcare including medication, regular review from a Consultant Psychiatrist and support from Community Psychiatric Nurses. When unwell, Patricia Ferguson would typically be overwhelmed with negative thoughts and emotions on a particular issue. This led to her completed suicide. The clinicians working with Patricia Ferguson considered that particular type of interventions which can only be undertaken by a clinical psychologist would be of benefit to Patricia Ferguson.

The inquest heard evidence from Nottinghamshire Healthcare NHS Trust regarding staff establishment within CMHTs. A clinical psychologist was employed by the CMHT working with Patricia Ferguson but was unable to take on new patients as there was going to be a planned period of extended absence.

The inquest heard evidence that clinical psychology was a ‘precious resource’ within the CMHTs. In terms of clinical psychology posts, the inquest heard that in some CMHTs within Nottinghamshire there is a full time equivalent post and in other teams this may be a shared post, or a less than full-time equivalent post. No teams have more than one clinical psychologist.

I was satisfied that Nottinghamshire Healthcare NHS Trust have implemented measures to make the best use of their clinical psychologists by means of a new internal protocol.

(1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular.

(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths.