Peter Lawrence
1 Jul 2019 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. lack of joint multi-disciplinary/agency care plan
“lack of a joint multi-disciplinary/agency care plan (between Local authority and Mental Health Trust) which could have resulted in delays in a timely response to known relapse indicators”
2. inconsistent care coordination for patient with history of disengagement and relapse
“A more assertive approach with consistency of care coordinator for a patient with a history of disengagement and relapse could possibly have been implemented reducing the likelihood of disengagement with services and promoted necessary concordance with medication”
3. delayed or inadequate mental health act assessment following concerns about self-care and disengagement
“A decision to admit to hospital under the mental health act following concerns being raised about self-care and disengagement could potentially have followed a coordinated MDT review and mental health act assessment and prevented deterioration in his mental health”
4. inadequate follow-up engagement and monitoring after tribunal discharge
“The agencies involved placed too much reliance on this decision and follow up engagement and monitoring with PL reduced becoming inadequate”