Leah Ratheram
15 Mar 2017 · Coroner Louise Hunt · Birmingham and Solihull
A similar concern from this report was raised again 5 times later. See the linked reports.
The coroner's concerns
1. lack of coordinated care for young adults
“Adults aged between 18 - 25 now have mental health services provided by two organisations - Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis”
2. information not shared effectively
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process. It was unclear how staff from each organisation would access each other's records when patients present to one or other of the services.”
3. lack of early involvement of approved social worker
“The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed. There is a concern that lack of involvement of this speciality at any early stage will affect the quality of mental health act assessments and the safety of patients.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed.”
Later report
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
Closely relatedConfidence 0.92 · high
This report
“An approved social worked declined to be involved until the assessment had been completed.”
Later report
“Evidence at the inquest from the approved Mental health practitioner confirmed that key information and documentation were either unavailable and/or not asked for during the mental health act assessment on 14/04/19.”
Closely relatedConfidence 0.90 · high
This report
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
Later report
“different health organisations use different digital systems that do not communicate with each other.”
Identical hazardConfidence 0.90 · high
This report
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
Later report
“There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.”
Closely relatedConfidence 0.85 · high
This report
“The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed.”
Later report
“there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”
Responses
No published response was found on judiciary.uk.