Wanda Stachurska
20 May 2015 · Coroner Bridget Dolan · West Sussex
The coroner's concerns
1. lack of awareness of SASH policies
“Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital”
2. use of untrained staff as interpreters
“use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence”
3. non-healthcare professionals interpreting
“staff members who are not health care professionals are asked to interpret during mental health assessments”
4. lack of training or guidance for interpreters
“Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role”
5. failure to conduct serious incident review
“Neither SASH nor SABP had considered that they should undertake a serious incident review into the case despite the death of a patient only a few hours after discharge”
6. delayed learning opportunities
“An opportunity to learn lessons from the above events has hence been delayed and potentially been lost”
Responses
2015-0199-Response-by-Surrey-and-Borders-Partnership-NHS-Trust.pdf ↗· Surrey and Borders Partnership NHS Foundation Trust
Stated action
“We have worked with our colleagues at East Surrey Hospital to ensure that a shortcut to Surrey and Sussex Hospital (SASH) policies is loaded onto all of our Psychiatric Liaison staff's computers to ensure ease of access for our staff. The SASH policy relating to using translation services has been made available as mandatory reading for our staff working at SASH.”