Richard Grant
21 Apr 2016 · Coroner Emma Brown · Birmingham and Solihull
The coroner's concerns
1. delayed referral to appropriate mental health team
“A clear risk to life clearly arises from patients who have been referred because of suicide attempt not being referred to the right team within a reasonable time.”
2. delayed communication to GP
“A letter detailing MB assessment and the outcome of it was not sent to Mr. [name redacted] GP until at least the 22nd December 2015”
Responses
2016-0157-Response-by-Black-Country-NHS.pdf ↗· Black Country Partnership NHS Foundation Trust
Stated action · May 2016
“AMHLS checklist is being developed and shared through team meetings which include prompts to review postcodes of patients to avoid incorrect referral route - Timescale for completion May 2016. (Completed)”
Stated action · May 2016
“Review of SPOR duty system is underway and will include ceasing practice of sending inappropriate referrals back to referrer. Clinician will continue to review all referrals and will forward / signpost referrals directly onwards. System will also include confirmation of receipt by telephone call. Timescale for completion May 2016. (Completed)”
Stated action · August 2016
“MHLS protocol being reviewed to encompass use of Common Assessment Tool and Clustering Tool to enable direct referrals from MHLS. Timescale for completion August 2016”
Stated action
“MHLS standard developed requiring ail letters are drafted within the same or following shift and are dispatched within 3 working days. (Completed)”