Rachal Murphy

8 Dec 2016 · Coroner Joanne Kearsley · Manchester (South)

The coroner's concerns

1. failure to conduct annual liver function tests
“There was a failure to undertake annual liver function tests in 2014 and 2015”
2. overlooked CAF documentation causing lack of GP involvement
“The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this case”
3. lack of referral clarity to psychological services
“There was a lack of understanding between medical professionals as to the means by which someone could be referred to Psychological services and whether there was a unclear message from Psychological services as to whether they were accepting referrals”
4. misunderstanding of CAMHS referral criteria
“Lack of understanding amongst medical professionals as to the cases which may or may not be suitable for referral to CAMHS”
5. delayed EEG reporting
“There was as significant delay in the reporting of Rachals EEG and the Court heard that this remained the case in respect of reporting of EEGs at the time of the Inquest”
6. delayed case allocation in Early Help Services
“The Court heard that there was a significant delay in the allocation of cases within Early Help Services and from the evidence the Court was not satisfied that this had been resolved”

2016-0401-Responses.pdf ↗· Medical Centre Stalybridge

Stated action · one month time frame

“measures have been put in place which have led to a significant reduction of delay in the allocation of cases”