Nora Bruton
25 Mar 2019 · Coroner Adam Hodson · Birmingham and Solihull
The coroner's concerns
1. inadequate dissemination of revised Clinical Risk Assessment training on harmful substance abuse
“A recommendation contained within the RCA report to carry out a review of the Clinical Risk Assessment training to incorporate clear risk formulation and management around harmful substance abuse, had been carried out, but this has had not been adequately disseminated to clinicians on the ground. Consideration therefore should be given to ensuring proper dissemination of this revised training to all treating clinicians as a matter of urgency”
2. gaps in crisis call communication protocol
“A review of the protocol for communicating crisis calls to all teams involved in care delivery to ensure a robust system of communication has not been acted upon. I heard evidence that prior to [the deceased]'s death there had been two separate incidents which led to significant patient harm and/or death which involved gaps in crisis call communication. Consideration should be given to ensuring this review takes place and the protocol appropriately modified as a matter of urgency”
3. prolonged review of Home Treatment Team model
“I heard evidence that the Home Treatment Team model was undergoing a process of review and overhaul, and that this process had taken approximately 18 months to date but there was no estimate of when this would be completed by. Consideration should therefore be given as to ensuring that this review is concluded as a matter of urgency and any changes to the Home Treatment Team model are implemented with similar urgency”