Daniel O'Sullivan
21 Oct 2022 · Coroner Christopher Williams · Inner South London
The coroner's concerns
1. failure to formulate a Care and Treatment plan identifying core treatment needs
“On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects: a) A failure to update a suicide self-harm risk assessment. b) A failure to formulate a Care and Treatment plan identifying core treatment needs.”
2. delayed police notification of patient absconding
“an earlier call to the police may have prevented the death, because [the deceased] was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48.”
Responses
2022-0330-Response-from-Central-and-North-West-London-NHS-Foundation-Trust-.pdf ↗· Central and North West London NHS Foundation Trust
Stated action · Three and a half years later
“The Trust began using SystmOne as its electronic clinical system in February 2019. As staff transitioned to the new electronic clinical record system they were learning about the operation and functionality of the system, and this also involved use of templates within the system and recording of information. It is fair to say that in March 2019 St Charles Mental Health Unit was at the start of the process of using SystmOne. Three and a half years later staff are now proficient in its use. This has”
2022-0330-Response-from-Department-of-Health-and-Social-Care-.pdf ↗· Department of Health and Social Care