David Buttriss
12 Jan 2018 · Coroner Emma Carlyon · Cornwall and the Isles of Scilly
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of information sharing between GP and mental health services
“Communication issues between the GP and mental health service”
2. unclear crisis response pathway
“lack of clarity of the appropriate method or pathway to deal with Mr [name redacted] on the night of 7" May when he was in crisis”
3. failure to disclose mental health history
“Patient's GP did not advise mental health services that Mr [name redacted] had a mental health history pre-2009”
4. missing patient profile transfer
“mental health services had requested a patient profile from the GP on 14.5.16 which was not received”
5. lack of record access for out-of-hours clinicians
“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
6. expression of suicidal ideation in note
“hand written note was found in the rear of annotated book "Loving Someone with Border-Line Personality" stating "Every night is a Friday night and every morning is a Monday Morning.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
Later report
“the out of hours GP reviewing Miss [name redacted] had no electronic access to her regular GP records”
Closely relatedConfidence 0.86 · high
This report
“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
Later report
“it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the”
Responses
2018-0010-Response-by-Cornwall-NHS-Trust.pdf ↗· Cornwall NHS Trust
Stated action
“implemeented a neww assessmeent service rreplacing the Single Pooint of Acceess to ensure thhat access to mental health serrvices is coonsistent annd effectivee. Each loocality areaa now has a designated rreferral admministrator to manage all referrals into Adult Mental HHealth Servvices and thhe administratoor requests a copy of tthe Patient Profile fromm the patiennt's GP for every referrral receiveed”
2018-0010-Response-by-Devon-Doctors.pdf ↗· Cornwall Health
Stated action
“Devon Integrated Urgent Care Service, in conjunction with Devon Partnership Trust, have community mental health practitioners (CMHP) working within our Clinical Assessment Providing out-of-hours medical care for the NHS across the county Devon Doctors Ltd - Company No.”
2018-0010-Response-by-NHS-England.pdf ↗· NHS England
Stated action
“NHS England proposes to disseminate a reminder to GPs to safety net urgent mental health referrals, reflecting in particular the inherent vulnerabilities associated with patients with mental health problems who may find it more difficult to engage with specialist mental health services when they are acutely unwell, and furthermore consider giving a patient written guidance on what to expect and when following a referral, given the impact mental health problems have on concentration and hence memory”