John Ashley

16 Mar 2020 · Coroner Penelope Schofield · West Sussex

The coroner's concerns

1. lack of updated care plan
“Mr [name redacted]'s Care and Treatment Plan was not updated when his mental health deteriorated”
2. lack of documentation in CareNotes
“Staff were not recording interactions with Mr [name redacted] in the CareNotes system and often emails were not copied into these notes”
3. lack of notification system for Lead Practitioners
“There was no system in place for Lead Practioners to be notified of an important entry in a patient's CareNotes where action was required”
4. lack of psychiatric review and team meeting updates
“Mr [name redacted] had not been seen by a Psychiatrist for over a year and there was no evidence that the deterioration of his mental health (and his non compliance with his medication) had been reviewed by the professionals weekly team meetings”
5. inconsistent risk assessment policy
“The Inquest identified that there was a discrepanciy in the Trust's own Policies as to when a Risk Assesment should be reviewed”
6. lack of coverage and handover procedure
“Save for the duty scheme there appears to be no procedure in place for another practictioner to cover a Lead Practictioner's case load or any formal handover when they are on leave”

Stated action · autumn last year

“we have introduced a new universal risk assessment and this captures risk events in chronological order and improves record keeping.”