Carol Robinson
30 Mar 2023 · Coroner Nadia Persaud · East London
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of medical review before discharge
“Mrs [name redacted] did not receive a medical review by a doctor within the Home Treatment Team prior to her discharge back to the care of her GP on the 25th April 2022.”
2. absence of comprehensive risk assessment before discharge
“Mrs [name redacted] did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022.”
3. lack of multidisciplinary planning and communication after discharge
“There was no multi-disciplinary team discussion to ensure a safe community plan following discharge from the Home Treatment Team. There was no communication with regard to the withdrawal of the Home Treatment Team's input, with the domiciliary care agency or family of Mrs [name redacted].”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The report also did not to any extent consider whether there was an adequate safety plan in place on discharge.”
This report
“There was no multi-disciplinary team discussion to ensure a safe community plan following discharge from the Home Treatment Team.”
Closely relatedConfidence 0.90 · high
This report
“Mrs [name redacted] did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022.”
Later report
“The medical record documentation for Mr [name redacted] had significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted]”
Responses
2023-0111-Response-from-North-East-London-Foundation-Trust.pdf ↗· North East London Foundation Trust
Stated action
“we attach a detailed action plan addressing the concerns raised by you.”