Adrian Jennings
19 Apr 2018 · Coroner Alison Mutch · Manchester (South)
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of integrated IT system
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care”
2. absence of clear discharge planning system
“there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health ward”
3. lack of commissioned mental health support service
“a need for a type of mental health support service had been identified by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service”
4. inability to capture police officer information in booking system
“Tameside Hospital cannot change their electronic booking in/triage system to allow them to include drop down boxes for key information such as the fact that Police Officers have brought an individual to the Hospital because it is a national IT system”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The discharge planning in relation to Mr [name redacted] was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this.”
This report
“there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health ward;”
Closely relatedConfidence 0.90 · high
This report
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care;”
Later report
“On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services.”
Closely relatedConfidence 0.90 · high
This report
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care;”
Later report
“It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems. The absence of such a unified records system creates obstacles as to the transfer of important clinical information between mental health and physical health specialists (and vice versa),”
Responses
2018-0111-Response-by-Department-of-Health.pdf ↗· Pennine Care NHS Trust
Stated action · 2015
“We revised the Code of Practice in 2015 and set out guiding principles to ' hups://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983 improve the care for patients.”
2018-0111-Response-by-NHS-England.pdf ↗· Pennine Care NHS Trust
Stated action · next two to three and a half years
“we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, fed by NHS England.”
2018-0111-Response-by-Tameside-Glossop-CCG.pdf ↗· Pennine Care NHS Trust
Stated action · process of investing
“The Tameside and Glossop Strategic Commissioning Board has recognised the need to develop and expand mental health support and is in the process of investing in additional services”