Gaia Pope-Sutherland
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of communication between neurology and psychiatry
“There is a complex relationship between epilepsy and mental health. It is essential for there to be good communication between those working in the 2 specialities when a patient is under the care of the 2 disciplines”
2. insufficient epilepsy nursing resources
“there are 10,000 adults in Dorset with active epilepsy and that she is 1 of 2 epilepsy nurses that cover the epilepsy nursing care across Dorset. She did not feel that there are sufficient resources to do all the things that need to be done in treating the patients”
3. lack of police training on epilepsy and mental health
“Police Officers provided evidence that they did not have training on epilepsy and mental health conditions such as post ictal psychosis, PTSD and those who have experienced sexual trauma”
4. ambiguous missing person policies
“some parts of these policies remain ambiguous or confusing. For example, in the Call Handling, Grading and Deployment Policy, there is no specific paragraph that explains that the Force Incident Manager should be notified of a high risk missing person”
5. poor record keeping in missing person investigations
“there was evidence of poor record keeping, including records not being made, or when they were made not beinq sufficiently detailed and records beinq 3 retrospectively made and changed without the records being clearly marked that the entries were retrospective”
6. absence of sexual harassment policy in mental health trust
“There is no policy currently in place within Dorset Healthcare University NHS Foundation Trust (DHUFT) that deals with how staff working within the Trust should handle incidents of sexual harassment or assault.”
Linked reports
Earlier report
“During the hearing it was noted that on a number of occasions record keeping was poor. This can make continuity of care difficult and it can lead to matters being missed.”
This report
“there was evidence of poor record keeping, including records not being made, or when they were made not beinq sufficiently detailed and records beinq 3 retrospectively made and changed without the records being clearly marked that the entries were retrospective”
Earlier report
“Although epilepsy was not found to be causative in the death in this Inquest, in another situation with a similar set of circumstances,”
This report
“Police Officers provided evidence that they did not have training on epilepsy and mental health conditions such as post ictal psychosis, PTSD and those who have experienced sexual trauma”
This report
“some parts of these policies remain ambiguous or confusing. For example, in the Call Handling, Grading and Deployment Policy, there is no specific paragraph that explains that the Force Incident Manager should be notified of a high risk missing person”
Later report
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment. Even where call handlers have real concerns that someone not returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to deploy is the same if the individual's address has not been visited, even when told that they would not go there.”
Responses
2022-0222-Response-from-Association-of-British-Neurologists.pdf ↗· Association of British Neurologists
2022-0222-Response-from-BCP-Council.pdf ↗· BCP Council
2022-0222-Response-from-College-of-Policing.pdf ↗· College of Policing
Stated action · 15 September 2022
“We recognise that policing must have some medical knowledge and this is provided through our first aid programme. This programme and medical knowledge makes explicit links to our vulnerability training. To ensure police responders are equipped to effectively respond to missing persons, our training focuses on managing the full spectrum of vulnerabilities through effective and proportionate risk management. In reality, this means that College standards require front line responders to ask good”
2022-0222-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2022-0222-Response-from-Dorset-Council.pdf ↗· Dorset County Council
2022-0222-Response-from-Dorset-Police.pdf ↗· Dorset Police
2022-0222-Response-from-Royal-College-of-Psychiatrists.pdf ↗· Royal College of Psychiatrists
Stated action
“The College very much recognise the issues you raise in relation to the lack of effective and consistent communication between services for people with neurological conditions and mental illness.”