Geraldine Kilborn
10 Dec 2014 · Coroner Andrew Tweddle · County Durham & Darlington
A similar concern from this report was raised again 4 times later. See the linked reports.
The coroner's concerns
1. lack of information sharing
“There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews”
2. inadequate review preparation
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
3. misleading assessment
“some ACCT review members had limited day to day experience of the deceased, whose temperament and presentation could change "like a light switch”
Linked reports
Closely relatedConfidence 0.70 · moderate
This report
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
Later report
“The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare.”
Identical hazardConfidence 0.90 · high
This report
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
Later report
“Available documentary information was not read or used, and pressures of time were cited to explain these failings.”
Identical hazardConfidence 0.90 · high
This report
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
Later report
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
Closely relatedConfidence 0.90 · high
This report
“There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews.”
Later report
“Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner's ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr [name redacted] ACCT daily record.”
Responses
2014-0532-Response-by-Care-UK.pdf ↗· Care UK
Stated action · April 2015
“From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model .The National Health Service Commissioning Board has procured seven services - GP Services including Pharmacy, Dental, Optometry, Community Care, Non-Clinical Substance Misuse, Mental Health and Support Services.”
2014-0532-Response-by-NOMS.pdf ↗· Care UK
Stated action
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
2014-0532-Response-by-Tess-Esk-Wear-Valleys-NHS-Trust.pdf ↗· Tees Esk and Wear Valley NHS Foundation Trust