Kate Hedges
3 May 2022 · Coroner Chris Morris · Manchester South
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of integrated record-keeping
“The court heard evidence that the Trust's Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to”
2. failure to follow safeguarding policy
“It is also a matter of concern that, following disclosure by Ms [name redacted] at a multidisciplinary meeting of a serious allegation to the effect that she was touched inappropriately by another patient, the Trust's own safeguarding policy was not followed”
3. distressing mixed-sex ward environment
“The court heard evidence to the effect that Ms [name redacted] often found the environment of a (mixed-sex) mental health ward distressing and difficult”
4. lack of trauma-informed design
“modern mental health service design and provision is not consistently or sufficiently trauma-informed”
Linked reports
Closely relatedConfidence 0.86 · high
This report
“The court heard evidence that the Trust's Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to”
Later report
“The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository.”
Responses
2022-0130-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2022-0130-Response-from-Greater-Manchester-Mental-Health.pdf ↗· Greater Manchester Mental Health NHS Foundation Trust
Stated action · end of July 2022
“the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans.”