Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of contingency planning for patient departure
The earlier warning
Matthew Groom · 12 Nov 2015 · ME Hassell, London Inner (North)
“The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist.”
judiciary.uk/prevention-of-future-death-reports/matthew-groom
What was promised
Stated action 1 · response to Matthew Groom (12 Nov 2015) · stated timescale: none stated
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
Stated action 2 · response to Matthew Groom (12 Nov 2015) · stated timescale: none stated
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
judiciary.uk/wp-content/uploads/2015/11/2015-0503-Response.pdf
What recurred
- 23 Oct 2017 · Sian Witheridge · ME Hassell · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Matthew Groom · 12 Nov 2015
“The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist.”
Later · Sian Witheridge · 23 Oct 2017
“One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms [name redacted] took any leave. However, this was an unenforceable plan, because Highbury Grove is an open facility.”
What happened next
No web check of the stated actions has been published for this chain.