Colin Blackburn
17 Sept 2021 · Coroner David Reid · Worcestershire
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of initial ACCT case review within 24 hours
“no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19”
2. delayed ACCT case manager assignment
“no ACCT Case Manager was assigned until 26.6.19”
3. lack of case manager involvement post-transfer
“no ACCT Case Manager had any effective involvement after Mr. [name redacted] was transferred from the Inpatients unit to Houseblock 6 on a Bo”
4. missing post-incident review
“no ACCT Case Review took place after the first ligature incident on 2.7.19”
5. ligature incident not recorded in NOMIS
“the second ligature incident on 2.7.19 was not documented on Mr. [name redacted] NOMIS record”
6. delayed ACCT case review
“the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr [name redacted] was interviewed by her and her further failure to make any entry within that document detailing her professional view.”
This report
“that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
Closely relatedConfidence 0.80 · moderate
This report
“(a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
Later report
“the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
Responses
2021-0311-Response-from-Practice-Plus-Group.pdf ↗· Practice Plus Group
Stated action · 31st October 2021
“The end date for the acceptance of paper referrals is 31st October 2021. From 1st November 2021, paper TAGs (Threshold Assessment Grid)1 will cease to be an option for referrals to the mental health team.”