Matthew Russell
27 Nov 2016 · Coroner Richard Travers · Surrey
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of proper and regular monitoring of repeat prescribed medication
“The proper and regular monitoring of all medication that is prescribed by way of a repeat prescription”
2. absence of structured care plans
“The preparation of structured care plans for each patient”
3. no follow‑up for missed appointments
“An effective procedure for following up patients who fail to attend pre-‐‐booked appointments with clinicians”
4. ineffective use of Read Codes to flag risk factors
“The effective use of Read Codes on the System One record, to flag up and highlight significant risk factors in a patient's care”
5. inadequate training of staff in ACCT procedure
“Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure”
6. caseworkers not attending ACCT Case Reviews
“Ensuring that caseworkers are aware of and attend ACCT Case Reviews for patients under their care”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“formal, written care plan should be provided to the distant residential home”
This report
“The preparation of structured care plans for each patient.”
Closely relatedConfidence 0.85 · high
This report
“Ensuring that caseworkers are aware of and attend ACCT Case Reviews for patients under their care.”
Later report
“The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”
Closely relatedConfidence 0.80 · moderate
This report
“Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure.”
Later report
“The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr [name redacted] was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement.”
Closely relatedConfidence 0.90 · high
This report
“Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure.”
Later report
“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”
Responses
2016-0430-Response-by-Central-and-North-West-London-NHS-Trust.pdf ↗· Central and North West London NHS Foundation Trust
Stated action
“prescriber is responsible for ensuring the ongoing monitorin effectiveness of medication, including side effects (GPs and CNWL Psychiatrists/ NMP). This is supported through: e In-line with community equivalence the GP would continue with repeat prescribing but would ensure the treatment plan assures them that the patient is in receipt of the appropriate level of supervision via primary care services. However, should the GP have any concerns around ongoing monitoring or psychological”