Peter Franklin
19 May 2014 · Coroner Patricia Harding · Mid Kent & Medway
The coroner's concerns
1. confusion in terminology between nursing staff or doctors and CRISIS team
“There was confusion in the terminology used between nursing staff or doctors and the CRISIS team when out of hours calls were made such that it was not clear between parties whether a referral, advice or assessment was sought”
2. lack of relevant information advice from CRIS!S team
“Relevant information/advice was not provided by the CRIS!S team to parties who had made referrais”
3. delayed information to GP preventing multidisciplinary team meeting
“Mr. [name redacted] GP would have initiated a multidisciplinary team meeting to address the increasing frequency of attendances at hospital had he been aware of the recent hospital admission, the subsequent involvement with the mental health team and the attendances at A&E. The documentation from both hospital and mental health trusts was subject of significant delays such that none of the letters to the GP sent by either trust from July onward arrived with the GP before Mr. [name redacted] died”
Responses
2014-0230-Response-by-Kent-Medway-NHS-Trust.pdf ↗· Kent and Medway NHS and Social Care Partnership Trust
Stated action
“We have developed a clear process outlining the pathway for urgent referrals through a referral flow chart which includes confirmation as to whether advice or assessment is being requested. This is being monitored by the Liaison Psychiatry Service Manager and at the monthly interface meeting between the two Trusts.”
Stated action
“The CRISIS team are only paged by the acute hospital outside the hours of operation of the Liaison Psychiatry Service. With the expansion of the Liaison Psychiatry Service the need to use the resources of the CRISIS team are decreasing.”
Stated action
“KMPT has developed a SMART tool (safeguarding, management and risk tool) for use between Accident & Emergency Departments and the Psychiatric Services which has been implemented in the east of the county and has been nominated this year for a National Patient Safety Award. This is based on guidelines produced by the National Institute for Health & Care Excellence and therefore compliant with national standards. It assists the Emergency Department staff to think through the immediate management”
Stated action
“The steps referred to above will also address this aspect of your report. In addition we have reviewed and updated the Liaison Psychiatry roles and Responsibilities Out of Hours Protocol. This provides improved guidance to staff. It has been reinforced to the CRISIS Team that we expect our staff to provide full and accurate information to carers and referring agencies.”
Stated action · as soon as received
“We are introducing a recovery card on discharge from hospital for the patient to have and which includes information as to what to do and who to contact in the event of crisis. The card has been designed and is at the printers and will be implemented as soon as received.”
Stated action
“KMPT is continuing to use the existing practice of a Written Discharge Notification being faxed to the GP within 24 hours of discharge including details of medication on the day of discharge. We are implementing an audit to ensure that this procedure is being followed which will include GPs.”
2014-0230-Response-by-Tunbridge-Wells-Hospital.pdf ↗· Maidstone and Tunbridge Wells NHS Trust