Helena Farrell
3 Jul 2014 · Coroner Ian Smith · Cumbria (South & East)
The coroner's concerns
1. inadequate referral system
“the referral system was not working adequately and the referral was not followed up after triage even though it was classified as urgent”
2. inadequate staffing levels
“Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers”
3. failure to recognise escalation of incidents
“Those dealing with [the deceased] failed to recognise the escalation of the incidents in which she was involved in terms of their seriousness and their increasing frequency”
4. unrealistic expectations of school nurse service
“they are responsible for provision of the school nurse service although they contract this out to the Partnership Trust but nonetheless the responsibility lies with Cumbria County Council”
5. lack of verified counsellor qualifications
“there was no proof of her qualifications or her competence nor of update and training or registration with any professional body”
Responses
2014-0309-Response-by-Cumbria-County-Council.pdf ↗· Cumbria County Council
2014-0309-Response-by-Cumbria-NHS-Foundation-Trust.pdf ↗· Cumbria Partnership NHS Foundation Trust
Stated action · 48 hours
“The referral system has been significantly redesigned, as evidenced in the internal action plan at Appendix 1 (enclosed), points 5 and 6. The timescales for response to referrals deemed urgent is now 48 hours and any breaches are electronically flagged and investigated.”