Danny Sweet
29 Jul 2016 · Coroner Andrew Cox · Cornwall and the Isles of Scilly
The coroner's concerns
1. difficulty assessing risk of self-harm
“Mr [name redacted] presented in equivocal and contradictory fashion. Accordingly, he was very difficult to assess and it was equally difficult for clinicians to form a view of the likely risk he posed to himself”
2. delayed referral to community mental health team
“the very day after a Consultant [name redacted] contemplated informal admission into hospital, a nurse from the HTT felt able to refer Mr [name redacted] to the Community Mental Health team where he was not seen for a month”
3. presumption of best case without safeguards
“whether it was appropriate simply to presume the best case scenario”
4. lack of consistency checks in assessment process
“whether or not it was appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions”
5. inadequate handling of capacity and declining treatment
“how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating”
Responses
2016-0275-Response-by-Cornwall-NHS-Trust.pdf ↗· Cornwall Partnership NHS Foundation Trust
Stated action · end of February 2017
“we propose to launch a review into the clinical risk assessment of people who present with suicidal thoughts or acts across each of our services and in particular the Trust's use of the STORM”