Kieran Hubbard
23 Dec 2019 · Coroner Nigel Meadows · Manchester (City)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delayed inpatient bed placement
“The failure by GMMH to expedite the search for and securing an inpatient bed which a consultant psychiatrist has clinically decided was appropriate to provide a safe and supervised environment for ongoing assessment and treatment for a patient with a serious diagnosed mental disorder who had made a very recent attempt to kill themselves”
2. information gap
“2 There was a failure by GMMH to fully and properly discover and record urgently or ina timely manner exactly what information was apparently required by PCFT tn order to facilitate the provision of a bed”
3. clinical decision override
“The decision to abandon the search for a bed was taken by healthcare professionals without knowledge of exactly what information, if any, PCFT required to consider the request and without updating the psychiatrist in charge of the deceased care”
4. communication breakdown
“If it is not possible to change or alter the "out of area" catchment area for mental health trusts then GMMH and PCFT should ensure that there are quick and reliable methods of communication between to secure a bed as soon as possible”
5. lack of safety guidance
“There did not appear to be any specific guidance , policy or protocol to assist healthcare staff in advising patients to stop driving motor vehicles or using machinery whilst in a mental health crisis”
6. investigation shortcomings
“There were failures in the post death investigation process which may result In the true circumstances not being tdentified and steps taken to prevent continuation or recurrence of circumstances which may cause or contribute to a future death”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“It does not appear that following the death of the deceased, there has been any internal review or reflection by MCC about the processes involved in this case”
This report
“There were failures in the post death investigation process which may result In the true circumstances not being tdentified and steps taken to prevent continuation or recurrence of circumstances which may cause or contribute to a future death”
Responses
No published response was found on judiciary.uk.