Louise Henry
16 Jan 2015 · Coroner Sophie Cartwright · Derby & Derbyshire
The coroner's concerns
1. misunderstanding of CPA roles and responsibilities
“The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co- ordinators for the purposes of the Care Programme Approach”
2. failure to follow discharge procedures and identify risk triggers
“both the CMHT and the Recovery Team of DCC ensure that when discharging patients all necessary processes and procedures indicated in policies are followed by the lead professional and / or care co-ordinator and that discharge letters sent to GPs and to patients identify risk relapse triggers and indicators to ensure re-assessment if there are signs of deterioration in mental health and speedy referral back to secondary mental health services if required”
3. ambiguity of service names causing confusion
“There is a misunderstanding in respect of the Recovery Team from DCC and the Recovery Team within the CMHT and potential for confusion between professionals and service users due to there being 2 services operating under the title "Recovery Team" operated by different agencies namely DCC and the CMHT”
4. underutilisation of risk information recording facilities
“GPs do not appreciate the use that can be made of the Special Patient Note facility and Right Care plan facility on the EMIS system operated by GPs”
Responses
2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust.pdf ↗· Derbyshire Healthcare NHS Foundation Trust
Stated action · 27 March 2015
“The Council and DCHFT intend to review this matter at the forthcoming "Service Manager Interface Meeting" to be held on 27 March 2015”
2015-0013-Response-by-NHS-England.pdf ↗· NHS England