James Agius
7 Oct 2024 · Coroner Sonia Hayes · Essex
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. incomplete risk assessment for Mr Agius after transfer from Home Treat Team
“significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted] following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr [name redacted] attempted to take his own life”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“When [the deceased] was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.”
This report
“significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted] following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr [name redacted] attempted to take his own life”
Closely relatedConfidence 0.90 · high
Earlier report
“Mrs [name redacted] did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022.”
This report
“The medical record documentation for Mr [name redacted] had significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted]”
Closely relatedConfidence 0.90 · high
This report
“significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted] following his transfer following crisis intervention with the Home Treat Team”
Later report
“There was no robust risk assessment carried out by the Mental Health and Wellness team.”
Responses
2024-0535-Response-from-NELFT.pdf ↗· North East London Foundation Trust
Stated action · 2024-11-03
“The Trust has completed a thematic review of patient safety incidents with the intention of identifying themes and patterns occurring within these. Resulting from this was the establishment of Trust wide workstreams aimed to address the identified gaps and then embed learning around these across the Trust. Of pertinence to the concerns raised in this instance, is the Improving Quality of Record Keeping and Clinical Documentation workstream.”