Graeme Kidd
23 Jul 2014 · Coroner Jacqueline Lake · Norfolk
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. locum doctors lack access to electronic care notes and records
“Locum Doctors do not have access to electronic CareNotes and other electronic records and systems relating to Patients”
2. locum doctors unaware of local mental health support teams and referral criteria
“Locum Doctors are not aware of the various local mental health support Teams available and the criteria which should be used when considering referral to an appropriate part of the service”
3. gps cannot directly refer patients to mental health service without physical health check
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay in cases requiring urgent referral”
4. no one available to advise patient on medication use when prescribing doctor absent
“~ Inthe absence of the prescribing Doctor, no-one was available to advise the patient as to how the medication was to be taken”
5. action plan implementation delayed until 30 September 2044
“Although an Action Plan has been put in place with regard to the matters of concern (1) to (4) above, the Plan is not to be implemented until 30 September 2044”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay in cases requiring urgent referral”
Later report
“It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out”
Closely relatedConfidence 0.90 · high
This report
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay”
Later report
“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
No published response was found on judiciary.uk.