Anne Morris
18 Dec 2017 · Coroner Christopher Williams · London Inner (South)
The coroner's concerns
1. lack of contact with friends and relatives
“staff at the Priory Hospital did not make contact with friends and relatives after [the deceased] had consented to them being contacted”
2. absence of written discharge plan identifying responsible HTT
“Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that [the deceased] was agreeable to health care professionals speaking to [name redacted] and [name redacted] regarding support with her mental health issues.”
3. lack of responsible HTT for discharge address
“Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge”
4. failure to proactively contact Priory Hospital for discharge plan
“Oxleas HTT do not appear to have proactively contacted the Priory Hospital for a written discharge plan prior to, or at the time, of the home visit on the 25/6/17”
5. lack of awareness of Anne's willingness for mental health contact
“Oxleas HTT do not appear to have _ been aware of [the deceased]'s willingness for mentai health professionals to contact egarding community support with her suicide risk”
Responses
2017-0383-Response-by-Oxleas-NHS-Trust_Redacted.pdf ↗· Oxleas NHS Foundation Trust
Stated action
“In the event that the information, including a detailed discharge plan is not received within 24 hours for patients transferred from an inpatient unit, the Home Treatment Team now contact the referring organisation to request that this is sent immediately and if not available they have a discussion about their recommendation for further treatment.”
2017-0383-Response-by-Priory-Group.pdf ↗· The Priory Hospital
Stated action · 2018
“Please note that we have reviewed and re-launched Priory Healthcare Policy HO2: Admission, Transfer and Discharge and made reference to the involvement of family, friends and carers in the discharge planning process (paragraph 5.1e). A rolling programme of training webinars which detail policy and practice is planned for 2018 and discharge planning will feature as part of these webinars.”