Leya Adris
8 Nov 2023 · Coroner Emma Brown · Birmingham and Solihull
The coroner's concerns
1. failure to refer Miss Adris to secondary mental health services
“On the 13th March 2023 Miss [name redacted] had a telephone review with [REDACTED], GP at The Park Medical Centre, who recorded that she had been taking [REDACTED] for 2 weeks, had spoken to the primary mental health worker and had been referred to 'Our roots' for therapy and had an appointment. She also recorded:”
2. lack of secondary mental health service consideration of GP referrals
“I am concerned that it is not safe that there is no consideration of that referral by secondary services and the GP's opinion that secondary services need to be involved is unilaterally over-ruled”
3. lack of awareness among GPs about referral rejection
“not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected”
4. risk to life from missed secondary mental health assessment
“If there are grounds for a GP to believe review and assessment is necessary by secondary services, it creates a risk to life if that review does not take place”
5. underestimation of patient deterioration by primary mental health staff
“the primary mental health practitioner did underestimate the significance of the report of daily deterioration and a new difficulty concentrating for a patient with a history of serious mental illness”
Responses
2023-0433-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
Stated action
“We have now liaised with the staff involved in order to be able to respond to your concerns in relation to the GP referral system to secondary mental health services and communication to GPs in respect of the same. Community Mental Health Services have been undergoing significant transformation since April 2021. In line with the attached national programme of work the government committed significant investment in Community Mental Health Services to integrate the 'front door' of Mental Health”
2023-0433-Response-from-Birmingham-and-Solihull-.pdf ↗· Birmingham and Solihull Integrated Care System