Mark Daniels
1 Jun 2015 · Coroner ME Hassell · London Inner (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of timely crisis team visits and communication
“the crisis team: - to visit Mr [name redacted] twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr [name redacted] was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not”
2. lack of clinical direction
“lack of cohesion and clinical direction”
3. risk of future deaths
“risk that future deaths will occur unless action is taken”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“- to visit Mr [name redacted] twice a day, despite a plan so to do;”
Later report
“The mental health nurse assessed Mr [name redacted] as rational and having good insight, despite the fact that Mr [name redacted] once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found.”
Responses
2015-0208-Response-by-Camden-and-Islington-NHS-Trust.pdf ↗· Camden and Islington NHS Foundation Trust
Stated action
“Following the inquest into the death of Mr [name redacted] you noted the following failures by the Crisis team: to visit Mr [name redacted] twice a day despite a plan to do so; to record why twice daily visits were not attempted; to communicate within the team and with the two Crisis houses; to consider hospital admission despite the fact that Mr [name redacted] was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill”