Louise Turner

7 Sept 2016 · Coroner Lydia Brown · Exeter and Greater Devon

The coroner's concerns

1. inadequate mental health care after discharge
“The Devon Partnership trust had no adequate mental health care for [the deceased] after she was discharged. There was inadequate contact and no explanation at Inquest as to why this had not taken place.”
2. ineffective duty system and buddying arrangements
“The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case.”
3. expectation of patient self‑initiated contact
“There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact. In cases of severe mental health, this does not appear to be appropriate or realistic, and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this belief.”
4. absence of female intensive care beds for psychiatric patients
“There are no female intensive care beds for psychiatric patients in Devon. This does not match the desired parity of mental health care with physical health care. Devon Partnership Trust needs to consider future planning and provision to ensure the needs of patients can be met.”