Lindsey Hassall
30 Nov 2017 · Coroner Alison Mutch · Manchester (South)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of record keeping of verbal information from police officers to RAID practitioners
“There is no provision for a record to be kept of the information, which Police Officers provide verbally to the RAID practitioners in the s.136 suite”
2. destruction of contemporaneous notes
“The notes relating to that engagement were not input into the electronic system at the time.”
3. inaccessible documentation to staff
“The documentation held by Pennine Care was not easily accessible to all of the staff working for Pennine Care”
4. failure to discuss or make referral after GP receipt
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“That the GP felt it was sufficient for him to simply discuss the deceased's care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process.”
This report
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked.”
Closely relatedConfidence 0.90 · high
Earlier report
“The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.”
This report
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made.”