Paul Dunne
21 Feb 2025 · Coroner Andrew Harris · South London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of risk recognition and assessment
“A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act”
2. failure to document and act on risk
“A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient's life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer”
3. inadequate application of A&E policies to mental health staff
“Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff”
4. inadequate electronic record integration
“MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records. MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU.”
This report
“A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will,”