Sarah Keen
4 Mar 2024 · Coroner Patricia Harding · Mid Kent and Medway
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of information to carer
“The enhanced carer had not been told the reason that she was providing one to one care for [the deceased], was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that [the deceased] was a risk of deliberate self harm including by overdosing on prescribed medications. She was not aware that [the deceased] had been discharged with seven days of medication or that her medication was being held on her behalf by another in the community. Although it was unusual for her to accompany”
2. absence of medication recommendations
“The note left by the psychiatrist on the medical records did not contain any recommendations as to medication. The psychiatrist was aware that [the deceased]'s medication was being held by her support workers as a result of the risk of mismanagement by overdosing. He was also aware that it was policy for the hospital to dispense 14 days of medication on discharge. He did not consider asking the discharging doctor to not provide [the deceased] with any medication on the basis that there was already a prescription”
3. ambiguous abbreviation DSH
“The note left by the psychiatrist on the medical records contained the abbreviation DSH. it was clear from the evidence given at the inquest that this was not universally understood by the medical team to refer to deliberate self harm.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The evidence was that Mr [name redacted] lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr [name redacted] did not wish information about him to be shared.”
This report
“The enhanced carer had not been told the reason that she was providing one to one care for [the deceased], was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that [the deceased] was a risk of deliberate self harm including by overdosing on prescribed medications.”
Closely relatedConfidence 0.85 · high
Earlier report
“Carers were not advised about any behaviours that might indicate an increased risk”
This report
“was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that [the deceased] was a risk of deliberate self harm”
Closely relatedConfidence 0.90 · high
Earlier report
“Carer breakdown is likely to have increased the risks of suicidality on discharge as this was not addressed during the hospital admission nor on discharge”
This report
“The enhanced carer had not been told the reason that she was providing one to one care for [the deceased], was not aware of any issues in relation to mental health”
Responses
2024-0123-Response-from-Darent-Valley-Trust-and-Kent-Medway-NHS-and-Social-Partnership.pdf ↗· Kent and Medway NHS and Social Care Partnership Trust
Stated action
“Staff should record their handover to the enhanced care nurse to explain the risks to harm if they are not present.”
Stated action
“Once admitted to the ward, staff should seek to understand if patients admitted following overdose have any remaining medication at home, and if so, what quantity.”
Stated action
“The discharge notification should indicate that a reduced amount of medication has been prescribed and the reason for this recorded.”
Stated action
“A reminder to staff in both organisations has been circulated through Trust wide communications in regard to the use of abbreviations in patient records.”
Stated action
“Consider monthly interface meeting with agenda to include potential risk spots, developing shared learning and practice changes and building a culture of collaboration.”