Marcus Hance
7 Jun 2018 · Coroner Guy Davies · Isles of Scilly
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of integrated mental health support for drug dependency
“[the deceased] was in a position where he was getting support with his drug dependency from the drug and alcohol team but was not able to access support for the mental health issues which were associated with the drug dependency.”
2. sequential treatment of dual diagnosis
“The approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed.”
3. premature discharge from CMHT
“The discharge from CMHT on failing to attend two appointments.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed.”
Later report
“The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT.”
Closely relatedConfidence 0.85 · high
This report
“The discharge from CMHT on failing to attend two appointments.”
Later report
“clients referred to the Trust were too easily discharged”
Responses
2018-0173-Kernow-NHS-Trust.pdf ↗· Kernow Clinical Commissioning Group
Stated action · December 2018
“To review the approach taken in cases of non-attendance at mental health appointments, and whether attempts to contact service users should be undertaken or alternatively to involve the police if there are concerns for the individuals welfare..”
2018-0173-Response-by-Cornwall-NHS-Trust.pdf ↗· Cornwall NHS Trust
Stated action · September 2018
“the Trust will be working in partnership with NHS Kernow as outlined in their response”