Paul Hyde
5 Dec 2014 · Coroner Veronica Hamilton-Deeley · Brighton & Hove
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed referral for medication review
“On the 14" April 2014, GP Dr. [name redacted] having anxieties expressed to him by one of the Community Mental Health Workers concerning [the deceased]'s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to [name redacted] who advised him that he should refer Mr. [name redacted] back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15" duly, 2014 and this”
2. lack of follow up after missed referral
“It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. [name redacted] not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to”
3. inadequate re-referral system
“From the point of view of Mr. [name redacted], the re-referral system was not fit for purpose. In the event, Mr. [name redacted] took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up”
Later report
“Mr [name redacted] was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him.”
Responses
2014-0527-Response-by-Sussex-Partnership-NHS.pdf ↗· Sussex Partnership NHS Trust
Stated action
“A further action was a review of the triage function/process to include increased involvement from Consultant [name redacted] and additional members of ATS. All clinical triage meetings have a Consultant [name redacted], lead nurse, and administrator present. Following Mr [name redacted] neues Associate Specialist has been invited to attend the triage meetings on a regular basis.”