Luke Whitelaw
27 Nov 2023 · Coroner Ian Potter · Inner North London
The coroner's concerns
1. lack of re-admission to hospital
“Mr [name redacted] re-admission to hospital was indicated as early as 2 February 2023; however, he was not re-admitted to hospital, informally or otherwise.”
2. lack of urgent psychiatric review
“A verbal referral was made for Mr [name redacted] to be urgently reviewed by a psychiatrist following the appointment on 2 February 2023, but not acted on.”
3. lack of clear risk documentation
“Discussions and assessments of risk should be clearly documented”
4. inadequate risk formulation
“Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions”
5. missed opportunities in deterioration monitoring
“missed opportunities identified in relation to LW's self-reported deterioration following his discharge from hospital which do not appear to have been fully explored”
Responses
2023-0486-Response-from-Oxleas-NHS-Foundation-Trust.pdf ↗· Oxleas NHS Foundation Trust
Stated action · December 2023
“Oxleas Acute Mental Health Patient Flow and Bed Management policy (updated in December 2023) provides guidance on the purpose of an inpatient admission; and actions to be taken when Crisis Resolution and Home Treatment Team (CRHTT) identify that someone's clinical needs indicate that an inpatient bed is required”
Stated action · 2023
“The CRHTT policy and training for staff includes guidance on assessing and managing risk, and changes to the risks and clinical presentation”
Stated action · July 2024
“In 2023 an improvement plan was put in pace for this clinical team to address gaps which were identified during the investigation and gaps which were identified as a result of day-to-day oversight. This plan is monitored by the service director and the clinical director for the Acute & Crisis Directorate and will continue until such time that we are satisfied that the care provided is to the standard needed, and for at least until July 2024”
Stated action · March 2023
“The Greenwich CRHTT has received DICES training, delivered by Association of Psychological Therapies. DICES Risk Assessment and Management System helps a practitioner assess risk using a system of checklist whereby all the risks that a client in crisis may be susceptible to are asked and explored by the practitioner”
Stated action · 16th January 2024
“The most recent audit carried by the Crisis services Manager on 16th January 2024 demonstrated that out of 34 cases reviewed, 28 of the risks assessment were of expected standards”