Finnulla Martin
29 Apr 2015 · Coroner ME Hassell · London North (Inner)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. failure to record suicidal statements
“The police call handler who spoke to Ms [name redacted] did not record that she said:”
2. lack of clarity on police information protocols
“the Camden and Islington Trust psychiatry liaison team (doctor and nurse) operating at Whittington Hospital on the night of 15 November 2015, were not wholly clear about the protocols for receipt of information from police officers bringing patients into hospital on a voluntary basis.”
3. skipping triage record review
“The team then saw a patient without waiting to obtain the triage record created by Whittington Hospital Trust staff.”
4. failure to assess suicide ideation
“The doctor did not ask Ms [name redacted] about thoughts of suicide within the context of her earlier declaration that she would die that night.”
5. failure to assess risk to others
“He did not ask her about any thoughts of harming another person, regardless of the fact he was not aware that she had threatened this.”
6. lack of contextual investigation
“He did not address his mind to what had led up to the police being called for Ms [name redacted], nor who had called them.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The doctor did not ask Ms [name redacted] about thoughts of suicide within the context of her earlier declaration that she would die that night.”
Later report
“There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.”
Responses
2015-0173-Whittington-Health-NHS-Trust.pdf ↗· Whittington Hospital NHS Trust
Stated action · 01/08/15
“Development of care Guidelines to be a a) June 2015-On_ | The set of guidelines and agreement guidelines relating to signed off at August track. The police patients brought into the 2015 ED Board and | Consultant in guidelines have _| (draft v3 attached)”
Stated action · 01/08/15
“To implement use of a | Trust. Version 3 mental health Proforma to Professional in progress Minutes and action improve the quality of development (attached).”
Stated action · June 2015
“To develop a new operational June 2015 A Meeting terms of Terms of reference group between Whittington Health ACUIe reference agreed”
Stated action · End of July 2015
“For all Camden and Provide written guide on use of End of July 2015 {slington Foundation Emergency Department computer Trust”
Stated action
“Undertake staff training on the tool and complete audit to review the impact”