Elsie Leaver

1. 1. lack of pertinent psychiatric history in GP summary

   “the GP summary did not contain pertinent psychiatric history that would have assisted the hospital clinicians to identify Mrs [name redacted] depression and specifically her suicidality.”

2. 2. failure to take reasonable psychiatric history

   “doctors at SGH do not take a reasonable psychiatric history as part of their clerking and thus fail to make a proper holistic assessment of the patient and potentially miss the opportunity to manage risks such as those in this case which may lead to death”

3. 3. lack of training on HIE information access

   “doctors at SGH need training on the information available on HIE and how to access it”

4. 4. lack of formal psychiatric liaison cover at QMH

   “NHS South West London Integrated Care Board has made no formal provision for psychiatric liaison cover at QMH, despite there being such a clear clinical need for this that the team from psychiatric liaison have felt compelled to provide informal telephone advice for the last 10 years”

5. 5. lack of formal psychiatric advice availability at QMH

   “the lack of formal psychiatric advice availability at QMH puts vulnerable patients at increased risk, since the only way to properly access such advice is for them to be sent by LAS ambulance to A&E at SGH, when they are physically frail, given that QMH is a rehabilitation unit”

No published response was found on judiciary.uk.