Maureen Campbell-Scott

“The GP had sent the referral to the wrong team of the mental health trust. The referral then got lost between the receiving team and the correct team (the older age mental health team). This resulted in a 4 month delay in [the deceased] receiving an assessment.”

“There were often delays (in excess of 14 days) in the delivery to the GP of clinic letters from the mental health trust. Often, the clinic letters contained requests for the GP to make changes to medication.”

“The prescribing by the GP did not always follow the direction given by the psychiatric team.”

“In times of acute mental health crisis, medication is often rapidly changed/supplemented. Mrs [name redacted] had 7 changes in her medication regime between 21 November 2016 to 23 February 2017. It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist team.”

“At the time of the Inquest hearing, there had been no joint meeting between the mental health trust and the GP practice to consider the best way forward in terms of referrals to the service; prescribing during times of dynamic medication changes and general communication between the GP and the psychiatrist.”

“It is accepted that the concerns in this case are unlikely to be restricted to the Fullwell Cross Surgery. If a joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices.”