Carl Ellson
20 Dec 2022 · Coroner Louise Hunt · Birmingham and Solihull
The coroner's concerns
1. inadequate urgent mental health referral pathway
“On 13/07/22 Dr [name redacted] GP needed to arrange an urgent mental health review as Dr [name redacted] had presented with suicidal ideation. The GP had significant difficulties trying to contact the Mental health team with messages giving incorrect numbers. My concern is that the system for GPs to contact mental health teams for urgent reviews is not clear nor safe.”
2. burdensome patient‑initiated crisis contact
“Once contact had been made and a request was made for Dr [name redacted] to be assessed by the mental health team, the system in place is for the patient to call the mental health practitioner. My concern is that the patient is likely to be in crisis, which is why a referral is being made, and the burden should not be put on them to make the call.”
3. lack of GP knowledge of urgent psychiatric referral process
“The GP caring for Dr [name redacted] on 13/07/22 was unaware that she could make a request for a psychiatric review of the patient. The inquest heard how this was not well known by local GPs. My concern is that GPs should be fully aware how to request an urgent psychiatric review for patients.”