Emma Burbury
11 Nov 2021 · Coroner Andrew Cox · Cornwall and Isles of Scilly
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. missed opportunity to engage dual diagnosis patient
“It was accepted in evidence that it was "very regrettable" [the deceased] was not taken on to caseload after her assessment in July 2017”
2. limited information sharing between services
“CMHT staff have read-only access to WAWY notes and records”
3. premature discharge from treatment
“clients referred to the Trust were too easily discharged”
4. inappropriate discharge based on diagnostic criteria
“patients referred to the Trust who did not fall within the strict parameters of a severe and enduring mental illness were discharged”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The discharge from CMHT on failing to attend two appointments.”
This report
“clients referred to the Trust were too easily discharged”
Responses
2021-0382-Response-from-Cornwall-Partnership_Published.pdf ↗· Cornwall Council
Stated action
“The Trust has engaged with partner agencies in contributing to the implementation of the systemwide Cornwall and Isle of Scilly Dual Diagnosis Strategy (Adults) 2019 to 2022.”
2021-0382-Response-from-Kernow-CCG_Published.pdf ↗· Kernow Clinical Commissioning Group