David Bennett
17 Feb 2025 · Coroner Sonia Hayes · Essex
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of access to primary care mental health System One records
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
2. unclear Operational Policy Mental Health Urgent Care Department pathways Appendices
“The Operational Policy Mental Health Urgent Care Department pathways Appendices are not clear and do not appear to accord with the implementation.”
3. inaccurate recording of recent contact in System One Records
“Recent contact with the primary care mental health records did not appear to be accurately recorded in the System One Records with suicidal ideation not recorded.”
4. failure to escalate request for GP appointment and urgent medication review
“Mr [name redacted] requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1st June did not escalate Mr [name redacted] to the GP or Community Psychiatrist when Mr [name redacted] was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health.”
5. failure to review open prescription for antipsychotic medication
“Mr [name redacted] had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber.”
6. lack of access to mental health and GP records by acute Trust nurse
“Mr [name redacted] attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse.”
Linked reports
Identical hazardConfidence 0.92 · high
Earlier report
“does not have access to a definitive record of the medication presently being taken by that patient (and/or their concordance with prescribed medication)”
This report
“The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse.”
Closely relatedConfidence 0.85 · high
Earlier report
“I am concerned about the fact, if that is indeed right, that some clinicians in the psychology service may not be able to access notes made by clinicians in either other hospitals or other parts of the county.”
This report
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
Closely relatedConfidence 0.85 · high
This report
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
Later report
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation other than very basic information on the INR platform on INR results and medication dose.”
Responses
2025-0089-Response-from-Essex-Partnership-University-NHS-Trust.pdf ↗· Essex Partnership University NHS Foundation Trust
2025-0089-Response-from-Mid-South-Essex-NHS-Trust.pdf ↗· Mid and South Essex NHS Foundation Trust
Stated action
“We are in the process of devising a 'Shared Care Record' with colleagues across the Integrated Care Board enabling unified access to patient records. The collaboration includes us, Essex Partnership University Trust (EPUT), Primary Care, Social Care and other key stakeholders set out below.”