Matthew Craven
22 Nov 2018 · Coroner Alison Mutch · Manchester (South)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of challenge or escalation process for mental health referrals
“He had long-term anxiety. Mental Health workers assessing him had repeatedly felt he needed to be seen by a psychiatrist. The referrals were rejected by the psychiatrist. There was no challenge or escalation process within the trust to deal with the situation.”
2. absence of agreed target timescales for routine psychiatric appointments
“A routine psychiatric out patient was offered after his mother indicated she would make a formal complaint. The inquest heard that there were no agreed target timescales for the offering of routine appointments.”
3. lack of documentation and rationale for RAID referral decisions
“There had been a series of attendances at the emergency department and RAID referrals. The inquest heard that there was no documentation or rationale provided for why RAID did not refer him to a psychiatrist.”
4. failure to share information and coordinate care across mental health services
“On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services. Information about that admission and encounter was not shared with wider mental health services even though they were part of the same trust.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care;”
This report
“On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services.”
Responses
2018-0365-Response-by-Pennine-Care-NHS-Trust.pdf ↗· Pennine Care NHS Trust
Stated action · end of February 2019
“We will develop a process and protocol for escalation to be used within the borough of Stockport by the end of February 2019.”
Stated action · end of February 2019
“Following review with the Lead Consultant [name redacted] the agreed target timescales for routine appointments is 12 weeks. Clear communication of the target timescales will form part of the action above.”
Stated action · end of February 2019
“Stockport borough will produce an escalation protocol for staff to use when there is disagreement regarding the need for a face to face appointment with a psychiatrist. This will be completed by the end of February 2019.”
Stated action · end of February 2019
“Pennine Care's alcohol liaison practitioners are moving to be based at Stepping Hill Hospital with the all age liaison mental health service and will form part of the same team which will significantly reduce the likelihood of any such concern arising again. The new model will be in place by the end of February 2019.”