Barbara Woodman
22 Dec 2023 · Coroner Darren Stewart · Surrey
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of unified record keeping system
“Although I found there was no causal link between any act or omission on behalf of those involved in the care of Ms. [name redacted], either from a mental health perspective, or by any other state agent, several matters have given me cause for concern.”
2. SCARF process out of hours
“The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“Lack of communication between hospital and home re mental capacity assessment”
This report
“staff speaking with [REDACTED] on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history”
Identical hazardConfidence 0.90 · high
Earlier report
“The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county.”
This report
“The ability of mental health clinicians to gain a complete picture of Ms. [name redacted] medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services.”
Identical hazardConfidence 0.95 · high
This report
“The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.”
Later report
“(3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours.”
Responses
2024-0100-Response-from-NHS-England.pdf ↗· NHS England
2024-0100-Response-from-Surrey-Police.pdf ↗· Surrey Police
2024-0100-Surrey-Council-and-Surrey-NHS-Joint-Response.pdf ↗· Surrey County Council