Paul Hills
19 Nov 2020 · Coroner Sonia Hayes · North East Kent
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. mental health appointments moved to virtual without risk assessment
“No risk assessment was completed on the issue of moving mental health appointments to virtual during the COVID-19 pandemic and how patients could be kept safe in the event of deterioration in his mental health. There was no plan in place for patients that required urgent assessment/review due to deterioration in their mental health.”
2. outdated care plan and risk assessment
“Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
3. risk information not shared with family
“Risk issues were not shared with the family even though [name redacted] was in lockdown with them and there were no discussions regarding sharing of information. He disclosed his dry runs of self-strangulation on 28th February and 16th April and his withdrawal/isolation from his family who had been very supportive of him. On 22nd April he disclosed he was looking for a rafter to harm himself from and there was an overreliance on his family as a protective factor in the absence of this knowledge being”
4. undocumented risk disclosures
“His risk assessment was not up-to-date and his disclosures during April were not documented.”
5. advice to avoid driving ineffective for safety
“[name redacted] was advised not to drive with his wife and children in the car when he disclosed strong thoughts to drive head long into oncoming traffic. This advice would not have protected [name redacted] or other road users.”
6. RAF Manston decommissioning affecting treatment
“Evidence was heard during the inquest that RAF Manston was being decommissioned and this impacted on the treatment available locally for [name redacted] and impacted on communications with the DCMH and the sharing of relevant information.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.”
This report
“His risk assessment was not up-to-date and his disclosures during April were not documented.”
Closely relatedConfidence 0.78 · moderate
This report
“Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
Later report
“There is no single composite risk assessment and care plan for service users that draws tooether all the relevant information for 2 a service user and identifies the plan in place (care plan and risk management plan) at any given time”
Responses
2020-0247-Response-from-MP-MOD-Redacted.pdf ↗· Ministry of Defence
Stated action · April 2021
“We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”
Stated action
“all routine clinical notes should be entered directly on to the patient's electronic file, and any handwritten notes shredded after that happens”