Margaret Stringer
17 Jun 2022 · Coroner Tim Holloway · Blackpool and Fylde
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. access to restricted items by resident without supervision
“Whereas the court heard evidence that Nightingales would not accept another patient with an equivalent medical profile/history and that, should a resident within one of Nightingales' homes require access to items to be restricted, they would be given 1:1 support pending a mental health assessment and discharge to a more appropriate facility, it was not possible for the home concerned to advise the court as to how and by whom the lead in question had been returned to Mrs [name redacted]. The concern arises”
2. isolation and loneliness
“The court heard evidence as to the potential detrimental effects of isolation and loneliness in the elderly, including evidence from the court appointed expert that isolation can be very corrosive, that it is the single most potent causative risk factor for depression in the elderly and that it can have a very detrimental effect on a person's mental state. There is a need for this to be known amongst staff. The concern arises as one member of staff gave (disputed) evidence that they had little”
3. inadequate information transfer on suicide risk
“The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs [name redacted] risk of suicide. They included the following: i. The care coordinator should have requested that the acute hospital make a referral to the Mental Health Liaison Team for a review; ii. It would have been good practice for a further professionals meeting / CPA review to have taken place prior to formal discharge and no later than just after discharge”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs [name redacted] risk of suicide.”
Later report
“There is a residual risk of non-communication of material information pertaining to patients' mental health between healthcare providers.”
Responses
2022-0187-Response-from-Adult-Community-Social-Care.pdf ↗· Blackpool Teaching Hospitals NHS Foundation Trust
Stated action · 2nd August 2022
“4. The Local Authority have reviewed the case again after receipt of the Reg 28 Report and consider that the conclusion of Dr is correct, in that there was adequate assessment and management of risk of suicide and that the placement at Nightingale was appropriate. There may be some details to correct (e.g. layout of Overview document) but having had that opportunity the Local Authority does not feel there is specific action arising from the Report of its own review of actions and procedure that”
2022-0187-Response-from-Blackpool-Teaching-Hospitals.pdf ↗· Blackpool Teaching Hospitals NHS Foundation Trust
Stated action · 15 September 2022
“BTHFT will collaborate with LSCFT and LCC to examine this LSCFT policy, and the interface with Acute Trusts and Local Authorities. We will cascade to the Matron, ward manager and consultant groups, what is expected of the respective organisations; to ensure that all relevant information, including suicide risk, is known, managed and communicated.”
2022-0187-Response-from-DAC-Beachcroft.pdf ↗· Blackpool Teaching Hospitals NHS Foundation Trust
Stated action
“As per the evidence of , Nightingale's is not a secure unit and a resident with a similar history to that of Ms [name redacted] would no longer be admitted to the Home. Should there be a concern in relation to a resident who was already admitted at the home, a system of 1:1 care would be implemented which would restrict access to any items. An urgent referral would therefore be arranged for assessment of the resident and the resident would be discharged to a more suitable placement/acute hospital.”