Jennifer Lewis
15 Apr 2019 · Coroner Roger Hatch · Kent (North-West)
The coroner's concerns
1. lack of coordination between mental health and physical health clinicians
“The failure to arrange consultation between the mental health doctors and the doctors responsible for her physical health”
2. inadequate care for patient needs
“The failure to provide suitable or adequate care for her needs”
3. inappropriate care at Centre
“The failure to provide appropriate care at the Centre”
Responses
2019-0003-Response-by-Oxleas-NHS-Trust.pdf ↗· Oxleas NHS Foundation Trust
Stated action
“All patients with a Long Term Condition (LTC), such as Ms [name redacted], are now held in a LTC register managed by the practice nurse in conjunction with the GP. This is in place and all physical health interventions and scheduled appointments are recorded within this register along with proposed future review dates.”
Stated action · beginning of this year
“All patients with declining physical health are discussed monthly at the complex care forum. The forum is chaired by the Mental Capacity lead for the directorate and attended by the Independent Mental Health Advocate (IMHA) to ensure patients' views are fully represented. This change was implemented at the beginning of this year.”
Stated action
“All relevant healthcare professionals, including the GP and dieticians where necessary, will be invited to six monthly Care Programme Approach (CPA) meetings for patients on the complex case caseload.”
Stated action · June 2017
“All patients' weight and height are now entered to the Malnutrition Universal Screening Tool (MUST) which has been available on our clinical records system, RiO, since June 2017.”
Stated action
“The named dietician will be responsible for appropriate reviews, follow up assessments and approval of meal plans.”