Eve Cullen
8 Jan 2015 · Coroner G U Williams · Worcestershire
The coroner's concerns
1. unactioned referral
“The failure to action the referral from the Queen Elizabeth Hospital”
2. delayed urgent referrals
“The failure to treat the 2 referrals on the 14" & 15 July 2014 as urgent (3) The lack”
3. inconsistent definition of urgent referrals
“The lack of any uniform agreement as to what constitutes an 'urgent' referral”
4. absence of standardized terminology
“terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being 2 service wide understanding of what is | expeceted in terms of timely action upon referrals that are made”
5. lost opportunity to intervene
“when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possible save the life of the patient”
6. missed intervention
“it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possible save the life of the patient”