Graeme Mathieson

1. 1. time constraints causing missed serious psychiatric condition

   “At page 20 of my judgement | found that at the appointment on 10 August 2016 the time constraints under which (ail was obliged to work meant that he was faced with trying to achieve the impossible. | said that | was sure that the very real constraints of time had had a direct impact on the outcome of the appointment. | said that it would have been better if the likely difficulties in this regard had been recognised at the point that Mr [name redacted] or his sister had asked to have an appointment. If”

2. 2. lack of shared learning among local practices

   “repeat the concerns set out at (1) above. | want to ensure that the lessons to be learned from this inquest are shared with all local practices in the hope that similar future fatalities may be avoided”

3. 3. confusion about care pathway after wrongful discharge

   “became apparent during the course of the inquest that a number of professionals (both GPs and care coordinators) were confused or unclear about the correct pathway for to follow once he had been wrongly discharged from the local CM HT. | indicated that | felt it may be sensible for Livewell Southwest to add a 'Professionals' tab or page to its website so that doctors and other professionals could refer to it in the event of uncertainty. | suggested that it may be sensible for a doctor”

4. 4. absence of clear professional guidance pathway

   “To consider the development of a 'Professionals' tab or webpage setting out current pathways for mental health patients to follow in specific circumstances as outlined at (3) above. To liaise with a GP representative to identify areas of current confusion and to assist in the creation of a clear and comprehensible summary document.”

5. 5. inflexible operational policy causing missed care

   “To consider whether, in certain circumstances, it may be appropriate to authorise care coordinators or other professionals to exercise clinical judgement and depart from stated operational policy. To assess the circumstances in which such a decision may be appropriate and the process to be followed. To consider the drafting of an express provision to this effect within the operational policy and the need for specific training for the clinicians concerned.”

6. 6. inadequate transfer process leading to patient safety risk

   “To consider whether there is a need to make the current transfer process more robust. To review recent transfers (over a specific timeframe) to identify whether there is an issue over failed transfers. If so, to consider what further steps may be necessary to strengthen the process.”

No published response was found on judiciary.uk.