Richard Walsh
25 Oct 2016 · Coroner Andrew Harris · London Inner (South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. future deaths
“there is still a risk that future deaths will occur unless action is taken”
2. defect in communications system
“The expert psychiatrist gave an opinion that there was a defect in the system of communications between professionals and agencies involved in the care of Mr [name redacted]”
3. inadequate information transfer of DPMFs and MHA assessments
“Custody Advisor informs the court that the national system was that the Detained Person's Medical Forms (DPMFs) were routinely scanned onto the police RMS system, but the Mental Health Act Assessment is not”
4. lack of communication of MHA assessment
“No report or letter or appropriate communication about the MHA assessment was completed in the police station to subsequent health care providers”
5. misleading risk assessment
“The Pre-Release risk assessment was completed by a custody officer, indicating that the deceased had no risks”
6. incomplete PER documentation
“The PER completed at HMP Highdown did not even reflect the limited information they had received from the police station three days earlier”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“There appeared to be not only serious failures of communication, but failures from inadequate processes of communication between custodial and health professionals, between police, court, health care and prison services”
Later report
“I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death. Information sharing between Prison Healthcare and Operational Prison Staff.”
Responses
2016-0377-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action
“You asked that the inquest findings be brought to the attention of those who lead the 'Departmental training programme' for Approved Mental Healthcare Practitioners (AMHPs) and consideration be given as to whether further guidance or training regarding Mental Health Act Assessments is required.”
2016-0377-Response-by-Hampshire-County-Council_Redacted.pdf ↗· Hampshire County Council
2016-0377-Response-by-Health-Care-Professions-Council.pdf ↗· Hampshire County Council
Stated action · 2018
“We will ensure that the new regulator is aware of this report and our correspondence.”
2016-0377-Response-by-Virgin-Care-Limited.pdf ↗· Hampshire County Council
Stated action · 19/12/2016
“We attach as Appendix A a copy of the”