Joanna Bowring
27 Jan 2016 · Coroner Patricia Harding · Mid Kent and Medway
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. patient and carer left assessment without clear understanding of service and care plan
“The patient and carer left an initial assessment conducted on 4”
2. carers not included in risk assessment process
“Carers were not routinely included in the risk assessment process and their views about the patient and knowledge of the patient were not actively sought”
3. carers not advised about behaviours indicating increased risk of suicide
“Carers were not advised about any behaviours that might indicate an increased risk of suicide”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Carers were not advised about any behaviours that might indicate an increased risk”
Later report
“was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that [the deceased] was a risk of deliberate self harm”
Responses
Joanna-Bowring-Response.pdf ↗· Kent and Medway NHS and Social Care Partnership Trust
Stated action · February 2016
“the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately,”
Stated action · ongoing
“The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care”
Stated action · February 2016
“The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for”
Stated action · June 2016
“The Service Line is to commission an external Risk Assessment Training company (STORM) to deliver Nationally Recommended Risk Assessment Training Trainors to key individuals”