David Chatburn
18 Mar 2014 · Coroner L J Hashmi · Manchester (North)
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. no referral to psychiatric services
“That there was no referral made by the GP to the Psychiatric services for an expert diagnosis/opinion/management and treatment plan. The GP considered that there was no need, as he felt clinically competent to manage the deceased's care and in any event, had a special interest in mental health, although he conceded that he was not formally recognised as a GP with a Special Interest ('GPwSpi') and whilst confident in his ability to manage the deceased's care, his area of special interest was in”
2. inappropriate medication prescribing
“That the GP did not consider the appropriateness of the medication prescribed, particularly in light of the patient's past mental health history - preferring to rely upon the presumed, anecdotal preferences of the community psychiatrists.”
3. inability to refer to community psychiatrist
“That the GP was unable to refer the deceased, as a new patient, directly to the in-house community based psychiatrist, thus effectively defeating the object.”
4. insufficient referral to specialist services
“That the GP felt it was sufficient for him to simply discuss the deceased's care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process. Such discussions were not necessarily case specific in any event but rather, general in nature.”
5. lack of contemporaneous record keeping
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
6. non-use of validated assessment tools
“That the GP did not use a recognised assessment tool, as an adjunct or otherwise, in his clinical evaluation of the deceased. He felt that they were ineffective and of little, if any, vaiue.”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
Later report
“Poor record keeping, predominantly on the part of the nursing staff.”
Closely relatedConfidence 0.80 · moderate
This report
“That the GP felt it was sufficient for him to simply discuss the deceased's care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process.”
Later report
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked.”
Identical hazardConfidence 0.90 · high
This report
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
Later report
“There was evidence to show that record keeping was poor and at some points non-existent.”
Responses
2014-0126-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action · 1 April 2014
“From 1 April 2014 patients with a mental health condition have had the same legal rights as physical health patients at first outpatient appointment to choose the provider that will deliver their care.”