Nicholas Harrison
24 Apr 2024 · Coroner Kirsten Heaven · Swansea Neath and Port Talbot
The coroner's concerns
1. inadequate mental health act assessment
“I heard evidence during the inquest that in January 2021, March 2021, and December 2021 the [name redacted] family made three formal requests for a mental health act assessment under the MHA 83 in respect of their son REDACTED] in their capacity as [REDACTED] Nearest Relatives (NR). On receipt of a NR request, the local social services authority (City and County of Swansea ('CCoS')) is under a legal duty pursuant to s.13(4) MHA 83 to make arrangements for an Approved Mental Health Practitioner ('AMPH')”
2. limited medical record access for s.12 doctors
“I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient's medical records if they are employed by SBUHB.”
3. overcrowded acute mental health ward
“I heard evidence that Ward F of Neath and Port Talbot hospital is being used as the Single Point of Admission ('SPOA') for all adults requiring hospital admission in the locality for assessment of their mental illness.”
Responses
2024-0224-Response-from-City-and-County-of-Swansea-.pdf ↗· City and County of Swansea
2024-0224-Response-from-Swansea-Bay-University-Health-Board-2.pdf ↗· Swansea Bay University Health Board
Stated action · 3rd April 2024
“formal meeting has been held between the Service and Head of Adult Services and Tackling Poverty from CCOS, to identify specific actions”
2024-0224-Response-from-Swansea-Bay-University-Health-Board.pdf ↗· Swansea Bay University Health Board
Stated action · immediate effect
“Please ensure that any plan of care is placed at the front of clinical notes or where a digital record is used (WCCIS) that the plan of care is on the digital front page.”
2024-0224-Response-from-Welsh-Government.pdf ↗· NHS Wales
Stated action · May 2024
“The Welsh Government has set up a National Strategic Programme for Mental Health in May 2024. This is being led by the NHS Executive, our delivery function within NHS Wales. An immediate focus for the mental health programme was the establishment of a Mental Health Patient Safety Programme, which all health boards are actively engaged in. There are five workstreams within the patient safety programme which cover procedural, relational, environmental, psychological and discharge areas.”