Danny Anderson
25 Jul 2024 · Coroner Nadia Persaud · East London
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. inadequate risk formulation prior to discharge
“no evidence of any adequate formulation of risk prior to [the deceased]'s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to [the deceased]'s discharge from the community mental health team in January 2023”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“There was no evidence of any adequate formulation of risk prior to [the deceased]'s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to [the deceased]'s discharge from the community mental health team in January 2023.”
Later report
“including: Communication; Training & Supervision; Record Keeping; Discharge Planning; Care Planning; Risk Assessment.”
Closely relatedConfidence 0.85 · high
This report
“There was no evidence of any adequate formulation of risk prior to [the deceased]'s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to [the deceased]'s discharge from the community mental health team in January 2023.”
Later report
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early waring signs and triggers”
Responses
2024-0405-Response-from-Essex-Partnership-NHS.pdf ↗· Essex Partnership University NHS Foundation Trust
Stated action · 26th September 2024
“The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.”