Kevin Fitton
28 May 2021 · Coroner Veronica Hamilton-Deeley · City of Brighton and Hove
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. assumption of capacity without assessment
“There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr [name redacted] and a failure to use best interests policy appropriately.”
2. lack of specialist ABI support
“There was a failure to seek specialist support regarding Acquired Brain Injury (ABI).”
3. inadequate understanding of ABI effects
“There was a failure to understand the way Mr [name redacted] ABI impacted on his abilities.”
4. uncoordinated ABI and substance use effects
“There was a failure to understand how ABI impacted on Mr [name redacted] substance use and vice versa.”
5. poor inter-team communication
“Communication between the various teams and individuals were poor.”
6. absence of leadership and coordination
“Lead and Co-ordination were lacking.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“(4) There was a failure to understand how ABI impacted on Mr [name redacted] substance use and vice versa. (5) Communication between the various teams and individuals were poor. (6) Lead and Co-ordination were lacking.”
Later report
“Lack of effective Communication between police officers The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as [the deceased] who was not known to the police.”
Closely relatedConfidence 0.90 · high
This report
“(5) Communication between the various teams and individuals were poor.”
Later report
“I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.”
Responses
2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published.pdf ↗· Brighton and Hove Council