Adrian James
7 Mar 2024 · Coroner Fiona Wilcox · Inner West London
The coroner's concerns
1. lack of consultant assessment for high-risk patient
“That [the deceased], despite being a complex patient with multiple psychiatric diagnoses and at high risk of impulsive behaviour and suicide was not seen nor assessed by a consultant either prior to starting psychological therapy or when he deteriorated”
2. lack of proactive care during crisis
“That no pro-active care was considered for [the deceased] whilst he was in obvious mental health crisis in the last 17 days of his life”
3. insufficient risk assessment of impulsive suicide
“That insufficient consideration appeared to have been given to the risk of impulsive suicide with instead assessment focussing on his denial of increased active suicidal intent”
4. lack of follow-up after treatment interruption
“That no follow up call or assessment was made to [the deceased] when his treatment session was interrupted by police attendence, and the treatment call was cut off”
5. inadequate communication between PCN MDT and psychological treatment providers
“That there were inadequate communications between the PCN MDT and those providing the psychological treatment”
Responses
2024-0128-Response-from-Central-and-North-West-London.pdf ↗· Central and North West London NHS Foundation Trust
Stated action
“We are issuing additional guidance around managing risk of suicide in those with a diagnosis of Personality Disorder (or more commonly now known as Complex Emotional Needs) reminding staff to consider the need for assessment by a Consultant [name redacted].”
Stated action
“We have shared learning on this with the team and are updating our policies accordingly.”
Stated action
“We are part of interagency Suicide Prevention group for Kensington, Chelsea and Westminster. In addition, we recently held a Learning session entitled - Suicide Prevention Part 1: Understanding Suicide. We are also piloting a new way of caring for service users in South Westminster ("Open Dialogue") with the overall goal to enter into discussion and communication with different sources to ensure increased participation in the safety and treatment of the service user”
Stated action
“We are reviewing our guidance on this and will ensure staff are clear on action to be taken.”
Stated action
“We are reminding staff of the need for consistent and adequate communication amongst professionals involved in treatment.”
2024-0128-Response-from-NHS-England.pdf ↗· NHS England