David Thompson
12 Aug 2024 · Coroner Joanne Kearsley · Manchester North
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of safety plan
“no My Safety Plan commenced on admission or complete prior to his discharge”
2. lack of engagement with home based treatment team
“no engagement prior to discharge with the local Home Based Treatment Team”
3. lack of consultant consultation
“no consultation with the Consultants who had treated Mr [name redacted] at the Priory in Altrincham only a few weeks earlier”
4. lack of 48 hour follow up call
“no 48 hour follow up call to Mr [name redacted] following his discharge, as per Priory Policy”
5. lack of discharge risk assessment
“A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided”
6. lack of standard care plans implementation
“no evidence that the four standard care plans had been opened during Mr [name redacted] inpatient stay”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in [the deceased]'s presentation on the 10th November.”
This report
“A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.”
Closely relatedConfidence 0.90 · high
Earlier report
“The court heard differing evidence from staff working at The Priory Hospital, Cheadle and from the Peripatetic Director of Clinical Services as to what the organisation's expectations were in respect of care plans, and specifically the degree of adherence which were required to them.”
This report
“There was no evidence that the four standard care plans had been opened during Mr [name redacted] inpatient stay.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“The Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician.”
This report
“A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.”
Responses
2024-0443-Response-from-Greater-Manchester-NHS.pdf ↗· Greater Manchester Integrated Care Board
Stated action
“We will also take this report to the Mental Health Clinical Effectiveness Group for discussion and shared learning.”
2024-0443-Response-from-Pennine-Care-NHS.pdf ↗· Pennine Care NHS Trust
2024-0443-Response-from-Priory-Group.pdf ↗· The Priory Group