Charlotte Comer
13 Mar 2023 · Coroner David Reid · Worcestershire
The coroner's concerns
1. lack of consistent care coordination
“During the 21⁄2 years in which [the deceased]'s mental health care was provided by the Trust, she had total of 8 different care coordinators. Furthermore, in those 21⁄2 years there was a 5 month period when [the deceased] had no appointed care coordinator at all. The care coordinator role is particularly important for a patient with such a complex case history as [the deceased].”
2. override of MDT decision by senior clinician
“The erroneous decision to pause [the deceased]'s referral to the Priory Hospital for specialist treatment for Body Dysmorphic Disorder was taken by a senior clinician acting on her own, despite a Multi-Disciplinary Team meeting having decided that the referral was appropriate.”
Responses
2023-0089-Response-from-Herefordshire-and-Worcestershire-Health-and-Care.pdf ↗· Herefordshire and Worcestershire Health and Care NHS Trust
Stated action
“The Trust fully recognises that the care coordinator system as it existed at the time failed [the deceased], and we are focused on ensuring no other patient has the experience that [the deceased] very regrettably did.”