Nicola Norman died by suicide in January 2020 and following her inquest at the end of last year, His Majesty’s Coroner has issued a Preventing Future Death report, just published. In the weeks leading to her death, Nicola rang a “Single Point of Access” (SPA) crisis line and she did so on more than one occasion. The SPA in north London where Nicola lived, was staffed by non-clinical professionals in the first instance who could involve clinically qualified NHS staff where necessary. The inquest went in to the detail of this, including hearing evidence from the SPA service manager / clinical lead.
- On 21st December, Nicola cut off the telephone call after stating her initial information that she’d had enough of life and felt like a burden — this was simply not followed up, either by the SPA itself or by referring her contact to others in contact with her, like the primary care mental health team.
- On 31st December, Nicola made a further containing expressed reference to two mechanisms which could cause death or serious injury and the SPA gave advice for Nicola to ring the primary care mental health team.
Tragically, Nicola died three weeks later, by suicide.
TELEPHONE CRISIS CARE
An increasing amount of mental health support is done via telephone – in addition to charity support and advice lines, which have existed for decades, there are a number of telephone based NHS services also. Many years ago, 111 in Cambridgeshire introduced an option available to anyone in their area to “press 2 if you’re calling about your mental health” and it put you through to a crisis based service accessible to all. As we saw the NHS Five Year Forward View (2016) and the NHS Long-Term Plan (2019), we saw the NHS enter in to a commitment to expand telephone access services and some of this was linked to attempts to reduce demand on the 999 system, including ambulance, police and emergency departments. I recall a detailed presentation about 111 in Cambridgeshire where it was pointed out that as little as 4% of all the “Option 2” demand was deflected to the emergency services because of immediate risks to life that required a 999 response, otherwise the service was able to support, assess and signpost people accordingly, including after the provision of face-to-face assessments within either 4hrs or 24hrs.
There are inherent difficulties with assessment which is not face-to-face — the obvious one being that the person answering the phone cannot see the patient. Mental health assessment begins with a physical overview to see whether someone’s presentation may be attributable to factors like injury, illness or intoxication some of which can’t be judged without in person contact. We’ve seen before some of the difficulties with telephone assessment in other PFD notices. For example, after a suicide in Warwickshire, a coroner examined police contact a couple of weeks before the death of a man who’d been met by some officers. During that encounter, the officers arranged for the man to speak to a street-triage nurse in a multi-agency scheme but it was done by telephone. At the inquest, the officers had stated they were advised by the nurse that no immediate action was required so they left him in situ, confident he’d been assessed by a nurse. At the inquest, however, the nurse pointed out that the discussion was not and could not be an assessment, because you cannot assess someone over the telephone.
It begged the obvious question about what the discussion was, if it wasn’t an assessment? – there wasn’t really an answer to that question but it gave rise to the coroner raising it as a matter of concern in the PFD notice. All professionals need to be clear what the various discussions and encounters amount to and I’m following an inquest at the moment which will raise similar issues about the need for a clear understanding of professional roles and for clarity of communication.
IMPLICATIONS
If the NHS is expanding its mental health offer to include a range of functions undertaken by telephone, 999 professionals (not just police, but including paramedics) arguably need to be aware of what this can mean in terms of what is possible by telephone and what is not.
And for myself, I’m left wondering in the sad case of Nicola Norman why the second call to SPA did not lead to a 999 call because of an immediate risk to life. It may be there is an understandable answer to this question because no PFD notice covers every aspect of a tragedy but the coroner is highlighting here someone who claimed to have attempted something could amount to a fatal mechanism.
The idea this wasn’t followed up on that day seems a little strange, without knowing more — you can discuss amongst those you know whether this should be a call to police, ambulance or the fire service (for forced entry to assist paramedics).
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2023
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
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