Matthew Groom
12 Nov 2015 · Coroner ME Hassell · London Inner (North)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed mental health assessment
“Most importantly, [name redacted] waited four hours in the emergency unit before he saw a mental healthcare professional for the first time. I heard that, at the time in these circumstances, it was not possible for a triage nurse to arrange for immediate mental health assessment.”
2. prescribed medication not administered
“Diazepam was prescribed but never administered.”
3. lack of contingency planning for patient departure
“The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist.”
4. failure to involve security for patient departure
“When [name redacted] did leave the department, the assessing doctor asked the nurse to call the police, but neither doctor nor nurse considered seeking urgent assistance from hospital security, given that they were by now both of the view that he would probably now have to be detained under section of the Mental Health Act.”
5. inadequate police welfare check request
“The nurse who then contacted the police did not then convey this to them, but requested a welfare check that would be satisfied by knowing he was with a family member.”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Most importantly, [name redacted] waited four hours in the emergency unit before he saw a mental healthcare professional for the first time.”
Later report
“Mr [name redacted] waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home.”
Closely relatedConfidence 0.85 · high
This report
“The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist.”
Later report
“One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms [name redacted] took any leave. However, this was an unenforceable plan, because Highbury Grove is an open facility.”
Responses
2015-0503-Response.pdf ↗· Whittington Hospital NHS Trust
Stated action
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
Matthew-Groom-Response.pdf ↗· Whittington Hospital NHS Trust
Stated action
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”