Emma Bray
16 Nov 2015 · Coroner Laura Johnson · London (East)
The coroner's concerns
1. incomplete medication history
“A proper medication history was not taken on assessment”
2. missing treatment history
“EB's treatment and medication history were not obtained from either public or private sector providers”
3. delayed referral
“Had EB's history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days”
4. inappropriate referral pathway
“EB should have been referred to an appropriate service, probably initially the BIT”
5. lack of follow-up
“Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment”
6. ignored family information
“Important information was provided by EB's family about the change in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports”