Kirsty Pritchard
17 Oct 2014 · Coroner Zafar Siddique · Black Country
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of timely communication of risk information
“The Root cause analysis report by the Black Country Partnership NHS Trust confirmed that there were issues in relation to the communication of information. Specifically, the evidence presented at the inquest confirmed that CHTT contact with Ms [name redacted] following discharge were not reported back to the inpatient Consultant in charge for review and assessment of risk of self harm in a timely fashion.”
2. inadequate risk management after discharge
“I am concerned that the ability to undertake effective management of patient risks of self harm and suicide ideation upon discharge may be compromised if the Consultant in charge or equivalent is not made aware of worsening symptoms and that effective systems are not in place to action this.”
3. delayed patient location despite police assistance
“In addition, I am concerned that there were deficiencies in the systems in place for contacting and finding the patient. In this case the patient had contacted the CHTT with a real and immediate risk of self harm and it took over 5 hours to find her despite the fact that the Police managed to locate her very quickly when they were subsequently contacted.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“there were deficiencies in the systems in place for contacting and finding the patient. In this case the patient had contacted the CHTT with a real and immediate risk of self harm”
Later report
“Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the 2nd October 2018 the HTT's only recorded attempt to contact Mr. [name redacted] before the 9th October 2018 was a single call”
Responses
2014-0565-Response-by-Black-County-NHS-Trust_Redacted.pdf ↗· Black Country Partnership NHS Foundation Trust
Stated action · April 2015
“The Trust processes, including the function and service provided by CHTT, are currently under review as part of a wider mental health strategy review. This is taking place in order to modernise services, improve quality of care and access to services. This review will also ensure a seamless service across both the adult and older adult population. The plan is to implement agreed changes to the current system by April 2015.”