Anthony Buckingham
9 Apr 2019 · Coroner Daniel Sharpstone · Suffolk
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of daily mental health team visits
“Daily visits from the mental health team”
2. lack of next of kin involvement
“Involvement of the next of kin (his father)”
3. lack of formal mental health act assessment
“Formal mental health act assessment”
4. lack of practice nurse involvement
“Involvement of the practice nurse”
5. lack of Corner house care facility use
“Use of Corner house care facility”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Formal mental health act assessment”
Later report
“no-one appeared to have looked at his mental health except to note that he was alcohol dependant”
Responses
2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust.pdf ↗· Norfolk and Suffolk NHS Foundation Trust
Stated action
“Daily visits from the mental health team”
Stated action
“The Trust obtains assurance of this improvement through means such as audit and its quality and safety reviews”
Stated action
“The report doesn't identify at which stage of care a request for a mental health act assessment may have been appropriate”
Stated action
“The team's current working process is to allocate an individual staff member to each service user; they have some additional responsibilities to ensure the care package is comprehensive and includes all other agencies”
Stated action
“Thinking of this wider partner network and the requirement for close working, our suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides”