Paul Barton
14 Oct 2021 · Coroner Gordon Clow · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. limited role focusing on avoiding inpatient treatment
“The approach of the Crisis Resolution Home Treatment Team of considering their role to be limited to avoiding the need for patients to receive inpatient treatment”
2. reliance on patient denial of suicidal intent
“staff members from Nottinghamshire Healthcare NHS Foundation Trust have placed great reliance upon their interpretation of a patient's intention and / or a patient's denial of ongoing suicidal intention”
3. inadequate investigation with false statements
“The quality of the Trust's own investigation into the circumstances of Mr [name redacted] death. It failed to identify themes of concern. It included many false and inaccurate statements, failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records”
Linked reports
Closely relatedConfidence 0.78 · moderate
This report
“The quality of the Trust's own investigation into the circumstances of Mr [name redacted] death. It failed to identify themes of concern.”
Later report
“it did not identify that a request from Mr [name redacted] GP in November 2022 for involvement of its service with Mr [name redacted] had not been actioned;”
Responses
2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_Published.pdf ↗· Nottinghamshire Healthcare NHS Foundation Trust
Stated action · 31 December 2021
“The updated procedure will be shared with all staff via email and discussed with all staff via team meetings.”