Christopher Larsen
13 Jun 2024 · Coroner Isobel Thistlethwaite · Rutland and North Leicestershire
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate multidisciplinary team meetings
“I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality”
2. incorrect information in multidisciplinary team documentation
“The MDT meeting therefore proceeded, and made decisions based upon, incorrect information”
3. unclear risk assessment rationale at discharge
“The Trust's SI report states that it was "unclear why it was felt the risks had subsided by the time of discharge on 3.12.2022"”
4. lack of post-discharge support for high-risk patient
“there was no planned support for Mr [name redacted] post-discharge other than some counselling which was due to start three weeks later”
5. inadequate serious incident investigation process
“I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust”
6. incomplete action plan for serious incident investigation
“it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“(4) As aresult, Mr [name redacted] and his main carer | left without support at a time when he was at high risk.”
This report
“Discharge Mr [name redacted] was discharged from the care of LPT on 3 December 2022, there was no planned support for Mr [name redacted] post-discharge other than some counselling which was due to start three weeks later.”
Closely relatedConfidence 0.90 · high
Earlier report
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”
This report
“The Serious Incident Investigation into Mr [name redacted] death did uncover and accepted some failings in relation to the care provided to Mr [name redacted].”