Patrick Soames
18 Apr 2023 · Coroner Edmund Gritt · South London
This report repeats 4 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. fragmented information sharing across agencies
“5 NHS Trusts and 3 police forces in different geographic areas had contact with [the deceased] in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about [the deceased]'s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear”
2. inaccessible GP records during out-of-hours
“GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the”
3. information siloing between local authority and NHS Trust
“I was informed at inquest that one local authority (in whose area [the deceased] resided) had been made aware by police of the risk to [the deceased] following one of his self- harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but [the deceased] did not reside in that Trust area. Those Trusts which did have direct contact with [the deceased] were never made aware of that piece of”
4. absence of national risk flagging system
“I heard evidence that there is no national 'risk flagging' system: for example, when a person attends an accident and emergency department having self- harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up.”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
This report
“it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the”
Closely relatedConfidence 0.90 · high
Earlier report
“The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult.”
This report
“5 NHS Trusts and 3 police forces in different geographic areas had contact with [the deceased] in the final month of his life and each thereby gained some information about the risk to him.”
Closely relatedConfidence 0.85 · high
Earlier report
“It is a matter of concern that delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories.”
This report
“However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department.”
Closely relatedConfidence 0.90 · high
Earlier report
“I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces, especially neighbouring forces who may both have contact with individuals.”
This report
“5 NHS Trusts and 3 police forces in different geographic areas had contact with [the deceased] in the final month of his life and each thereby gained some information about the risk to him.”
Closely relatedConfidence 0.80 · moderate
This report
“it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department.”
Later report
“The GP medical history summary, populated by the GP that a patient is registered to, is not always accessible to a GP out of hours surgery.”
Responses
No published response was found on judiciary.uk.