Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of formal liaison between NHS and private mental health providers
The earlier warning
Samiyo Farah · 30 Apr 2014 · Lisa Hashmi, Manchester (North)
“Communication/contact between transferring establishments - there is no formal policy/protoco! in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors”
judiciary.uk/prevention-of-future-death-reports/samiyo-farah
What was promised
Stated action 1 · response to Jonathan Zucker (26 Jun 2017) · stated timescale: 2nd November 2017
“The College is aware that CPA policy can be interpreted and applied differently across the country. Ideally a care co-ordinator will be able to negotiate patient discharges and their integration into the care of a new team. However, there are circumstances in which this is not straight-forward, e.g. if a section is ending or a person is being discharged from hospital.”
Stated action 2 · response to Caroline Forte (27 Apr 2023) · stated timescale: 2025
“The Trust has also shared with us a helpful learning briefing on Section 17 leave from inpatient wards. This will be shared with the national Regulation 28 Working Group regional representatives for dissemination across the seven NHS regions, to raise awareness of the issue with their Trusts and to encourage best practice.”
What recurred
- 26 Jun 2017 · Jonathan Zucker · Andrew Walker
- 27 Apr 2023 · Caroline Forte · Penelope Schofield · Closely related · confidence 0.86 (high)
- 15 Mar 2024 · Sarah Sutherland · Karen Henderson · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Jonathan Zucker · 26 Jun 2017
“That there was no requirement for ,or system for, a lead clinician from either the private or NHS treating teams to oversee and coordinate the care provided to Mr [name redacted] by the private and NHS mental health services.”
Later · Sarah Sutherland · 15 Mar 2024
“However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients.”
What happened next
No web check of the stated actions has been published for this chain.