Henry Heselton
18 May 2018 · Coroner Caroline Topping · Surrey
The coroner's concerns
1. incomplete mental health records
“The electronic mental health records were unclear. Vital information about Mr [name redacted] mental health history, including that he had attempted suicide in the past, was difficult to find. His most recent care plan did not record this. The information was not easy to extract for professionals needing to find information about a patient in a crisis”
2. communication breakdown between mental health teams and GP
“There was a lack of communication between the mental health teams and the general practitioner. The fact that contact had been made by with both the acute and community mental health team was not shared with his General Practitioner. This left her without relevant recent history to inform her clinical judgement when she was contacted by on the 7th September 2016”
Responses
2018-0152-Response-by-Southern-Health-NHS-Trust.pdf ↗· Southern Health NHS Foundation Trust
Stated action · January 2017 (evaluated in April 2018)
“The concern that vital information has not being readily available has been accepted and action taken to remedy this. There has been, since January 2017 (evaluated in April 2018), a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors: demographic, background, clinical history, psychological and psychosocial factors and”