Sally Poynton
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate discharge summary reflecting uncertainty in diagnosis
“During the course of these inquests, the evidence has revealed matters giving rise to concern.”
2. failure to inform Nearest Relative of statutory right to request assessment
“A failure to advise [the deceased], as Nearest Relative, of her statutory right to request [REDACTED] assessment under the MHA”
3. delay in updating RiO records with patient timeline
“A delay of five months in putting into the RiO records a detailed timeline provided by [the deceased] while [REDACTED] was an in-patient”
4. failure to discuss patient presentation with family despite collaboration directive
“A failure to discuss with [the deceased] or the maternal side of [REDACTED] family how he presented, notwithstanding a clear direction following a first ward round to 'collaborate' with the family”
5. lack of professional curiosity about substance use impact
“A lack of understanding or professional curiosity about drug-taking and the extent to which, if at all, this contributed to [REDACTED] presentation”
6. delayed response to GP referral due to staff shortages
“Community Mental Health Team”
Linked reports
This report
“A failure to advise [the deceased], as Nearest Relative, of her statutory right to request [REDACTED] assessment under the MHA.”
Later report
“The Nearest Relative details on the MH 1 form were not completed.”
Responses
2024-0267-Cornwall-Council.pdf ↗· Cornwall Council
Stated action · next 6 months
“We are continuing to work with colleagues through the Domestic Homicide Review process to identify actions stemming from the Senior Coroner's proposed recommendations.”
2024-0267-Response-from-Department-of-Health-Social-Care.pdf ↗· Department of Health and Social Care
2024-0267-Response-Integrated-Care-Board-Office-of-the-Clinical-Executive.pdf ↗· Cornwall & Isles of Scilly Integrated Care Board
Stated action · 8 July 2024
“The ICB has taken this matter seriously and the executive leadership of the ICB were presented with a paper in a formal executive group meeting. The paper provided an analysis of this issue and a proposal for how it should be addressed. The meeting took place on the 8 July 2024 and supported the proposal; which is described in this letter.”