Ellen Woolnough
28 Mar 2024 · Coroner Darren Stewart · Suffolk
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. discharge of patient from mental health services with failed engagement
“The adequacy of Norfolk and Suffolk NHS Foundation Trust's (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred”
2. downgrading of urgent referrals
“The adequacy of NSFT's Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals”
3. implementation of PSIRF framework
“Adequacy of the NHS England Patient Safety Incident Response Framework (PSIRF) to address serious incidents concerning patients and the implementation of this framework by NSFT”
4. loss of call recordings
“The failure by NSFT to preserve important evidence, in the form of recordings of calls between [name redacted] and the NSFT crisis call handler, at a time when it was on notice that this evidence would be important and relevant for the conduct of the Inquest”
Linked reports
Closely relatedConfidence 0.70 · moderate
Earlier report
“Under the proposed new system, in order to access the Norfolk and Suffolk Foundation Trust Borderline Personality Disorder service, those suffering from the condition would have to agree”
This report
“The adequacy of Norfolk and Suffolk NHS Foundation Trust's (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred.”
Closely relatedConfidence 0.80 · moderate
This report
“The adequacy of NSFT's Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals.”
Later report
“However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”
Responses
2024-0184-Response-from-NHS-England.pdf ↗· NHS England
Stated action · May 2024
“The implementation of a new Trust-wide Crisis Rehabilitation Home Treatment Team (CRHTT) Standard Operating Procedure (SOP) and handover document in May 2024.”
2024-0184-Response-from-Norfolk-and-Suffolk-NHS-Foundation-Trust-.pdf ↗· Norfolk and Suffolk NHS Foundation Trust
Stated action · end of June 2024
“The Trust has recently been reviewing and updating their Clinical Risk Assessment and Management Policy. This Policy is currently progressing through Trust internal governance processes and is due to be published end of June 2024, with a Policy implementation plan to be progressed during July/August 2024.”