Philip Denning
16 Feb 2016 · Coroner Heidi Connor · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. fragmented service provision for co-occurring substance misuse and mental health issues
“Patients with both substance misuse and mental health issues used to be managed under the same 'umbrella' - ie by Nottinghamshire Healthcare. Since October 2014, Nottinghamshire Healthcare has only dealt with a small subsection of these patients (broadly speaking, those with severe and enduring mental illness).”
2. information silo between substance misuse and mental health services
“The CRI is an entirely separate entity from Nottinghamshire Healthcare and has no access to RiO, Nottingham Healthcare's electronic record-keeping system. If, for instance, one of their patients had been seen regularly by Nottinghamshire Healthcare following overdoses, they would not be aware of this unless their patient told them about this.”
3. primary care misunderstanding of service pathways for dual-diagnosis patients
“It is also clear that there is a significant lack of understanding in primary care about how to access help for patients like [the deceased]. The respective roles of CRI, Nottinghamshire Healthcare and primary care talking therapies appear to be widely misunderstood.”
Linked reports
Identical hazardConfidence 0.92 · high
This report
“As | understand it, the question of patients giving their consent for access to RiO records by CRI (and indeed for Nottinghamshire Healthcare to have access to CRI records) has not been considered by either organisation.”
Later report
“(2) There is insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service).”
Responses
No published response was found on judiciary.uk.