Samiyo Farah
30 Apr 2014 · Coroner Lisa Hashmi · Manchester (North)
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of national observation guidance for children and adolescents in specialist mental health units
“Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units. At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues. The care needs of young people are quite different to those of adults.”
2. absence of formal transfer protocol between private sector and NHS causing communication breakdown
“Communication/contact between transferring establishments - there is no formal policy/protoco! in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors, thus risking that not all key information (both verbal and written) is properly communicated before, during and after transfer. Whilst progress is being made in this regard at local level following the death of Miss [name redacted] (and may well be the basis upon which any n”
3. inconsistent referral of Miss Farah to psychiatry across A&E attendances
“There appears to have been an inconsistency of approach following Miss [name redacted] admissions to A & E. She was referred directly to a Psychiatrist on the second attendance when she was clearly unwell but had not managed to self-harm but was not on the first attendance when she had taken an overdose. This also raises the question as to whether she ought to have been referred (to a Psychiatrist) on the 31° October 2012.”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units. At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues.”
Later report
“Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient's mental state and/or self harrm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded)”
Closely relatedConfidence 0.86 · high
This report
“there is no formal policy/protoco! in use/between the private sector and the NHS detailing steps that should be taken (and by whom)”
Later report
“Details of her consultations and treatments were not made readily available to those working in the NHS Trusts.”
Closely relatedConfidence 0.86 · high
This report
“Communication/contact between transferring establishments - there is no formal policy/protoco! in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors”
Later report
“there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other”
Responses
2014-0202-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care