Victoria Halliday
20 Oct 2016 · Coroner Lydia Brown · Leicester City and Leicestershire South
The coroner's concerns
1. lack of local psychiatric intensive care unit beds for female patients
“There are currently no local psychiatric intensive care unit beds for female patients and this means all female patients can only be placed out of area, potentially many miles away from home and local support.”
2. absence of community psychiatric nurse involvement
“There was no, or no effective, community psychiatric nurse involvement and this was a missed opportunity to monitor and assist [the deceased] when she was in the community.”
3. non adherence to care programme approach and NICE guidelines
“The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified.”
4. absence of local network for community support of patients with personality disorder
“There is no local network for the community support of patients diagnosed with personality disorder, although evidence suggested such networks were effective when adopted elsewhere.”