Roberto Bottello
16 Feb 2024 · Coroner Fiona Wilcox · Inner West London
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. failure to provide evidence
“CNWL failed in its duty of candour in relation to provision of evidence”
2. inadequate training of call handlers
“SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately”
3. incorrect communication by police officers
“police officers may need reminding to use the phonetic alphabet and using the word for the month in a person's date of birth”
4. neglect of cross‑doctor diagnosis consideration
“psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E as in this case”
5. inadequate out‑of‑hours psychiatric response
“most section 136 usage is out of hours when there is less resource to respond from psychiatric services”
6. inadequate window safety in high‑risk areas
“use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“That CNWL failed in its duty of candour in relation to provision of evidence in this case.”
Later report
“delay in fulfilling the Duty of Candour' obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice.”
Closely relatedConfidence 0.85 · high
This report
“That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.”
Later report
“The Section 136 Suite was completely inappropriate. [the deceased]'s mental health and behaviour declined further and ultimately this resulted in his death.”
Responses
2024-0087-Response-from-Central-and-NW-London-NHS.pdf ↗· Central and North West London NHS Foundation Trust
2024-0087-Response-from-Metropolitan-Police-Service.pdf ↗· Metropolitan Police Service
2024-0087-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“Concern number 6 - Psychiatric liaison nurses and psychiatric liaison doctors should have regard to diagnoses made by other doctors”