Maeve Boothby O'Neill - articles about her life, death and inquest

Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.
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Regulations 28 and 29, Coroners (Investigations) Regulations 2013 (external link, opens in a new tab) set out the procedures that apply to reports and responses. The Chief Coroner has also issued guidance on the process which you can access here: REPORTS – ACTION TO PREVENT FUTURE DEATHS
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https://www.judiciary.uk/courts-and-tribunals/coroners-courts/reports-to-prevent-future-deaths/

Issued reports are public and viewable here:

https://www.judiciary.uk/?s=&pfd_report_type=&post_type=pfd&order=relevance
 
Amw66 said:
@Valerie Eliot Smith
Is there a simple explanation for this ?

https://twitter.com/user/status/1839198895051620398



#MaeveInquest 10:00 Friday 27 September 2024 coroner@devon.gov.uk for the live link.
This is the 13th hearing. 1 witness who has submitted 3 separate statements. Why was he not called BEFORE HMAC concluded? Why has she not published half the facts heard? Whose court is it?
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Thanks for the mention @Amw66

I assume the first question refers to Dr Anthony Hemsley who is giving evidence tomorrow at the hearing when the Coroner will consider whether or not to write a Section 28 Prevention of Future Deaths Report.

Dr Hemsley was appointed as Medical Director to the RDUH Trust in June 2021, over half way through the period covered by the inquest. As such, he would have had little/no direct involvement in Maeve's case. The handling of Maeve's case was addressed during the main inquest hearing by the clinicians who were directly involved in her care.

I haven't seen Dr Hemsley's statements. However, I imagine that, given his position and the timing of his appointment, the relevance of his evidence goes to how the Trust has addressed the issues arising from Maeve's case since her death rather than adding anything further to what happened between January and October 2021. I assume that this is why the Coroner is hearing from him tomorrow and why he was not called during the earlier proceedings.

The other two questions in that X post are presumably rhetorical so any answer would be purely speculative in the absence of any further information.
 
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Valerie Eliot Smith said:
Thanks for the mention @Amw66

I assume the first question refers to Dr Anthony Hemsley who is giving evidence tomorrow at the hearing when the Coroner will consider whether or not to write a Section 28 Prevention of Future Deaths Report.

Dr Hemsley was appointed as Medical Director to the RDUH Trust in June 2021, over half way through the period covered by the inquest. As such, he would have had little/no direct involvement in Maeve's case. The handling of Maeve's case was addressed during the main inquest hearing by the clinicians who were directly involved in her care.

I haven't seen Dr Hemsley's statements. However, I imagine that, given his position and the timing of his appointment, the relevance of his evidence goes to how the Trust has addressed the issues arising from Maeve's case since her death rather than adding anything further to what happened between January and October 2021. I assume that this is why the Coroner is hearing from him tomorrow and why he was not called during the earlier proceedings.

The other two questions in that X post are presumably rhetorical so any answer would be purely speculative in the absence of any further information.
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Thank you
 
MEAdvocates Ireland tweeted
Dr H has stated that the Trust is not commissioned to provide treatment for severe & very severe ME at the time despite the older & newer published NICE guidance He says there is c limited guidance as how to care for Severe ME

Dr H: The recommended physical requirements for severe ME are beyond reasonable for an acute hospital A private side room would be provided with low stimuli, a multi discp team, clinical psychology, allied specialists
 
continued
Dr H: The consequences were that anyone requiring treatment in Devon they would provide care to there best possible standard With Maeve we worked within our available resource to provide care There are no pathways for severe ME in Royal Devon
 
Steve Fifield tweeted:
Coroner / Dr Anthony Hemsley
What was NHS guidance?
Symptom relief, non acute basis. Not severe. Energy management, Lifestyle changes. States a range of information on website.

Paul Keeble tweeted:
H. Guidelines at the time weren't helpful (2007). NHS guidelines makes no reference to inpatient treatment. No acute focus with CBT symptoms relief only.
 
ME Advocates Ireland tweeted:
Dr H: (gist) Something would need to change to accommodate Severe ME at national level

Coroner refers to need for a Regional services for Severe ME & Dr H agrees with her Dr H investigated the options for future patients & refers to the limitation of beds for Severe ME Refers to funding for Severe ME - no resources to fund a level of service needed
 
ME Advocates Ireland:
Dr H: only a small number of patients with Severe ME , 5 per year, come into RD&E They have 7 patients on their existing records though confined to home Refers to link with LC They expect up to 5 ptnts to require inpatient care

Dr H: refers to who he approached re need for specialist services No intent by ICB to commission No capacity Concerns taken seriously but would require another body Dr Marsh raised concern w Prof S Paris, Med Dir of NHS (gist)
 
Steve Fifield:
Coroner / Dr Anthony Hemsley Coroner not clear who she needs to approach. Believes it needs to be Government. Write to DHSC and NHS England. AH: Include Michael Marsh NHSE SW Region & Steve Moore Devon ICB

Jason S:
The Royal Devon prefers to treat severe/ very severe patients at home. Due to heightened awareness of ME the community matron can now assess deterioration & service provision for dietary interventions.
 
ME Advocates Ireland
Coroner understands that if someone like Maeve needed to see a dietician in own home they would now Dr H: the community matron would be very beneficial now Unfortunately in M’s case the GP was alone but now it would be different (gist)

It seems now that a community matron is available for patients confined to home That matron who ‘hold the ring’ coordinating care would liaise with Hosp based colleagues & assess needs & provide the necessary services & supports in the community (Devon)

Coroner refers to the huge responsibility Dr Shenton had without the role of the community matron now being referred to

Dr H: the community matron is a post holder who is fully equipped to contact all the right services & able to assess earlier the upstream of a crisis & to plan an in harmful admission ie able to divert the patient away from harm
 
MEAI continued:
Dr H: has thought about training to avoid harm Hospitals are complex places now so range of options available eg a ward that is co-owned by a consultant geriatrician is available Geriatrician has a deep understanding of many areas of physical & mental health

Dr H: There is now an e-learning platform available (NHS) of the requirements of ME patients Currently investigating if they can hold similar platform in electronic staff records in Devon that can be audited etc

Dr H: specific local informal training re Severe ME has been made available to staff in Bolum ward There are plans to train others, however it’s a matter for the future as very few people are admitted with the level of severity of this disease

Steve Fifield tweeted:
Coroner / Dr Anthony Hemsley What changes have there been locally (cont)? e-Learning platform is first stage now available. Stage 2&3 still in construction. Similar or same to be held on staff record. Would know that people had completed a course - looking at.
 
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