Ronald Harris
4 Oct 2023 · Coroner Hugh Bricknell · Herefordshire
The coroner's concerns
1. incomplete triage documentation
“Triage documentation was not fully completed”
2. patient not contacted as requested
“The patient was not telephoned as requested and as advised they would be”
3. lack of awareness of waiting time and transcript
“The Inquest was advised the triage Doctor was not aware of the waiting time for a routine appointment (4-6 weeks) nor did he consider the transcript of the telephone call”
4. no updated mental health triage protocol
“The Deceased died on the 5th June 2023. The Inquest was told that a significant event meeting on the 9th August 2023 had indicated a review of protocol criteria for triaging patients with mental health problems was being undertaken . The Inquest was held on the 27th September 2023 no revised protocol was advised”