Jamie Pilkington
22 Feb 2024 · Coroner Andrew Barkley · Staffordshire and Stoke on Trent
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. risk of suicide
“failure to complete the Risk Assessment in relation to his risk of suicide”
2. lack of exploration of suicidal ideation
“no exploration of his statement to the effect he was actively researching methods of taking his own life”
3. lack of medication review
“no exploration regarding efficacy/concordance with medication”
4. lack of coping strategies
“no discussion around distraction techniques, coping mechanisms or information about contact details for other services”
5. lack of social support assessment
“no discussion regarding his support network, next of kin etc.”
6. lack of care coordination
“no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“It is apparent that patients do benefit from regular 'ward rounds' or 'multi- disciplinary team meetings' (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings.”
This report
“There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team.”
Closely relatedConfidence 0.85 · high
Earlier report
“Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand”
This report
“During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.”
Closely relatedConfidence 0.90 · high
This report
“During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.”
Later report
“Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system.”
Responses
2024-0101-Response-from-Midlands-Partnership-NHS.pdf ↗· Midlands Partnership NHS Foundation Trust
Stated action · December 2023
“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide”
Stated action · December 2023
“When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide”
Stated action · December 2023
“An exploration of risk would entail a conversation around factors such as risk to self, risk to others or self- neglect. If during that conversation any risks are identified these would be explored in further detail to include intent, severity, access to resources and following this a robust safety plan formulated collaboratively between professional, the service user and carer (if”
Stated action · Ongoing
“The Overcoming Challenging Times plan is collaborative in nature, designed to enable the service user to identify changes in behaviours, risk and thought processes and empowers them to engage in activities that have previously proven effective in supporting them to manage their emotions and related risks”
Stated action · Ongoing
“Family and carer engagement; ensuring that families and carers are included in safety planning”
Stated action · Ongoing
“Monitoring; engagement in real time suicide surveillance, patient safety incident review and learning from deaths process”