Tyla Cook
17 Sept 2019 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. 11 week delay in accessing eating disorder service
“It was agreed at the CETR meeting on 9 August 2017 that [the deceased] was to be seen by the Eating Disorder Service. He was not seen until 25 October 2017. The evidence was the 11 week delay in seeing [the deceased] was due to a heavy caseload and the practitioner having to remove other cases from his caseload before he was able to work with [the deceased]”
2. absence of up-to-date written care and crisis plan
“There was no written up-to-date care and crisis plans in place. The most recent written care plan related to [the deceased] being an inpatient at the Dragonfly Unit, from where he was discharged on 9 August 2017. The written plans were therefore several months out of date. This is against Trust Policy. Evidence was heard that at a CETR meeting on 6 November 2017 a period of a further 3 months was requested to prepare an up to date written care plan. In the event, and despite the family's repeated requests”
3. lack of multi-disciplinary learning event on non-technical skills
“The Review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended a multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust, Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be developed and implemented to train staff on how to apply good non- technical skills (teamwork, leadership, task prioritisation and communication) when responding to an emergency. At the inquest it became clear”
Responses
2019-0299-Response-by-Norfolk-and-Suffolk-NHS-Trust.pdf ↗· Norfolk and Suffolk NHS Foundation Trust
Stated action · 9 August 2017
“1: In order to prevent delays accessing care when a service user presents with complex co-morbid mental health conditions the following process has been developed. The care coordinator will ask other teams to joint work and/or provide consultation to ensure all relevant expertise is promptly accessed. Input from another team will be prioritised according to risk and not held on a waiting list if there is an urgent need. Any concerns regarding capacity and access to care will be escalated to the”
2019-0299-Response-by-Norfolk-County-Council_Redacted.pdf ↗· Norfolk County Council
2019-0299-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust.pdf ↗· Queen Elizabeth Hospital
Stated action · February 2020
“on 4 November a meeting was held at Chatterton House in King's [name redacted] and present were senior staff from all of the key participants, namely the Director of Nursing and Quality Assurance - West Norfolk CCG (Chair), the Deputy Director for Patient Safety and Quality - Norfolk & Suffolk NHS Foundation Trust, the interim General Manager - East of England Ambulance NHS Trust, the Approved Mental Health Professional (AMHP) Team Manager - Norfolk County Council, and the Deputy Director of Patient Safety”
2019-0299-Response-by-West-Norfolk-CCG.pdf ↗· West Norfolk Clinical Commissioning Group