John Atkinson
29 Nov 2016 · Coroner Nicola Mundy · South Yorkshire (East)
The coroner's concerns
1. lack of updated risk assessments
“Lack of updated Risk Assessments when key events occurred or there was a significant deterioration in presentation”
2. failure of the care co-ordinator to identify changes in presentation and level of risk
“Failure of the care co-ordinator to identify changes in presentation and level of risk and to seek a doctors input”
3. absence of an effective and robust system to identify and then manage patients under the care of departing staff
“Absence of an effective and robust system to identify and then manage patients under the care of departing staff (for example care co-ordinator)”
4. lack of effective communication between mental health professionals at differing levels and also between those and the
“Lack of effective communication between mental health professionals at differing levels and also between those professionals and the patient and the patient's family”
5. difficulty in consultant psychiatrists accessing Home Treatment Team Services when they indicate a need
“Difficulty in consultant psychiatrists accessing Home Treatment Team Services when they indicate a need (since a change in emphasis in interpreting the guidelines from the end of 2014)”
Responses
2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust.pdf ↗· Rotherham NHS Foundation Trust
Stated action · February and March 2017
“The Trust has therefore commissioned some tailored STORM training (Skills based Training on Risk Management) due to be delivered during February and March 2017”