Johanne Blackwood
27 Jul 2023 · Coroner Sean Horstead · Essex
The coroner's concerns
1. lack of formal handover of Care Coordinator responsibility
“Evidence confirmed a conspicuous lack of clarity as to when, where and by (or between) whom any formal handover of responsibility as Care Coordinator (CC) for [name redacted] took place as between a number of CCs allocated to [name redacted] over a period of many months from the lead up to and following her discharge as an in-patient back to the community team on December 18th 2020 and through to early May 2021.”
2. absence of oversight responsibility after discharge
“Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, has the responsibilitv for oversight of patient carefollowing discharge, including responsibility for ensuring adequate and appropriate safety-netting is in place in the event of relapse, where a Care Coordinator is no longer in place/has not been replaced.”
3. lack of updated risk and care plans
“The community Risk Assessment, Care Plan and Security Plan for [name redacted] were not updated by a Care Coordinator between December 2020 and [name redacted]'s death.”
Responses
2023-0275-Response-from-Essex-Partnership-University-NHS-Fondation-Trust-.pdf ↗· Essex Partnership NHS Foundation Trust
Stated action · Trust wide implementation
“The service manager took this recommendation on board and has been working with colleagues and departments to produce a purposeful template that will form part of the Patient Electronic Record specific to the care coordinators' handover. This document has been approved, for implementation Trust wide, following a process of consultation and with comments gathered from all community services.”
Stated action · implementation
“The handover template (Care Coordinator to Care Coordinator Transfer of Care Document) will form part of the patient's electronic record and will be easily accessible to anybody working with the patient.”
Stated action · ongoing
“The Community Mental Health Team (CMHT) based at Grays Hall, as well as CMHT teams across the Trust have access to the Team caseloads via the Trust Intranet system”
Stated action · ongoing
“In the event that a new care coordinator is not available, the team ensure that those patients without an allocated care coordinator have direct contact from clinicians within the team.”
Stated action · monthly
“The team manager and team leads now receive monthly performance updates with regards to the various care standards compliance which include care plan and risk assessment which are then shared with the care coordinators for action.”
Stated action · ongoing
“the team ensure that those patients without an allocated care coordinator have direct contact from clinicians within the team. This is done through a clinical MDT approach; patients are prioritised according to their presenting need and contact is through the use of creating from the Duty Person and Buddy worker System.”