Sophie Boothe

“It became very clear in evidence that the overseas involvement was not properly flagged up when the CPE came to triage [the deceased]'s referral; this includes both the discharge summary and [the deceased]'s own self-referral via email whilst she was in Australia. The full discharge summary from Australia was sent by the GP along with his referral on the 8th May 2019 to ensure that all relevant information was shared at the earliest stage. These notes were either not fully reviewed and/or understood by the CPE and this appears to have contributed to the downgrading of [the deceased]'s referral. It became clear in evidence that the UK services did not understand that "Scheduled" is the Australian equivalent of being "Sectioned" and there was a lack of probity and curiosity to as what this meant and what treatment [the deceased] had in Australia; albeit that the evidence was not convincing (or even persuasive) that the Australian discharge summary had been thoroughly read at all on being received by the CPE . Overall, there appears, on the evidence, to be very poor communication between the departmental services and, as a result, opportunities appear to have been missed to fully appreciate [the deceased]'s full clinical presentation when making an assessment about the timeliness of appropriate interventions and assessments. I believe that whilst the service remains disjointed, with insufficient exploration of information sent from foreign jurisdictions, there remains a risk that future death will continue to occur.”