Marlene McCabe
11 Jun 2023 · Coroner Timothy Holloway · Blackpool & Fylde
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of understanding of urgent referral process
“There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made.”
2. inconsistent access to mental health records
“There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult.”
3. risk of missing mental health diagnosis due to substance misuse assumptions
“There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse.”
4. non-communication of material mental health information
“There is a residual risk of non-communication of material information pertaining to patients' mental health between healthcare providers.”
5. delayed assessment of intoxicated patients
“There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier 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.”
This report
“There is a residual risk of non-communication of material information pertaining to patients' mental health between healthcare providers.”
Responses
No published response was found on judiciary.uk.