Daniel Watson
18 Dec 2017 · Coroner John Gittins · North Wales (East and Central)
The coroner's concerns
1. missed opportunities to improve mental health
“multitude of care and service delivery problems and contributory factors in relation to the care and treatment of the Deceased which cumulatively represented missed opportunities to improve his mental health and the evidence given at the inquest by the social worker and community psychiatric nurse demonstrated a complete lack of understanding and empathy in relation to these issues”
2. inadequate staff training on risk assessment
“significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns towards a formal psychiatric assessment”
3. delayed transfer of care
“The Deceased was known to the Flintshire and Wrexham Community Mental Health Teams and had been allocated a social worker on the Wrexham Team on the 7* of December 2016 following a request from his Consultant [name redacted] following a lengthy delay in the transfer of his care from Flintshire”
4. absence of up-to-date care and treatment plan and risk formulation
“no evidence of any up to date care and treatment plan nor any evidence of comprehensive risk formulation”
5. lack of awareness of deceased by mental health teams
“The Deceased was known to the Flintshire and Wrexham Community Mental Health Teams”