Jonathan Meaney
24 Aug 2017 · Coroner ME Hassell · London Inner (North)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. delayed assessment in emergency unit
“Mr [name redacted] waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home”
2. failure to verify overdose intent
“When the mental nurse assessed Mr [name redacted] before discharge on Wednesday, 15 March, he did not question Mr [name redacted] assertion that he had not intended to take an overdose two days before”
3. misattribution of physical symptoms to mental illness
“The mental health nurse assessed Mr [name redacted] as rational and having good insight, despite the fact that Mr [name redacted] once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found.”
4. lack of multidisciplinary consultation before discharge
“The mental health nurse did not consult any other member of the team before clearing Mr [name redacted] as fit for discharge from a mental health point of view”
5. unfulfilled referral to GP for counselling
“who saw Mr [name redacted] decided to refer Mr [name redacted] to his general practitioner for counselling, though Mr [name redacted] had already said that he had not found the crisis team helpful.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“- to visit Mr [name redacted] twice a day, despite a plan so to do;”
This report
“The mental health nurse assessed Mr [name redacted] as rational and having good insight, despite the fact that Mr [name redacted] once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found.”
Closely relatedConfidence 0.85 · high
Earlier report
“Most importantly, [name redacted] waited four hours in the emergency unit before he saw a mental healthcare professional for the first time.”
This report
“Mr [name redacted] waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home.”
Responses
2017-0244-Response2.pdf ↗· Royal Free London NHS Foundation Trust
Stated action · November
“The nurse in question was an agency professional, employed by NHS Professionals. (NHSP). tn light of this case, he has been suspended from working at this level of expertise until the serious incident review has been completed.”
2017-0244-Response.pdf ↗· Royal Free London NHS Foundation Trust
Stated action
“we have asked to be provided with copies of CANDI's finalised Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately”