Helen Kerr
18 Sept 2024 · Coroner Caroline Topping · Surrey
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of timely mental health referrals
“Cogent information about Ms [name redacted] declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms [name redacted] was not provided with appropriate and timely referrals for mental health treatment.”
2. inadequate out-of-hours information sharing
“The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public.”
3. refuge staff unawareness of client's delusions
“The refuge was not made aware of Ms [name redacted] presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“- In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking”
This report
“(1) Cogent information about Ms [name redacted] declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to”
Identical hazardConfidence 0.95 · high
Earlier report
“The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.”
This report
“(3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours.”