Shannon Quinn
6 Sept 2019 · Coroner Zafar Siddique · Black Country
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inconsistent sharing of medical notes and care plans between agencies
“Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the statutory agencies and private sector. In particular, there was no sharing of medical notes/care plans between the Birmingham and Solihull and Mental Health Trust and Oak House”
2. inconsistent and minimal training for managing complex needs
“There was inconsistent and minimal training provided to Oak House staff in respect of managing SQ's complex needs by the Mental Health Trust”
3. lack of joint multidisciplinary care plan and insufficient contact with care coordinator
“There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence”
4. escalating risk of ligature use and self-harm incidents
“There was an escalating risk of use of ligatures and incidents of self-harm and little if any measures were introduced to try and provide a ligature free environment”
5. non-adherence to 5 minute observation for self-harm risk
“The patient observation level of 5 minutes was introduced to minimise risk of self-harm but not adhered to”
6. minimal training in resuscitation for Oak House staff
“Evidence emerged during the inquest that there had been minimal training for Oak House staff in performing resuscitation on patients. The training received included general first aid training by e-learning”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“No appropriate care plan was developed by the District Nursing Service.”
This report
“There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.”
Closely relatedConfidence 0.90 · high
Earlier report
“There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation.”
This report
“There was an escalating risk of use of ligatures and incidents of self-harm and little if any measures were introduced to try and provide a ligature free environment.”
Identical hazardConfidence 0.90 · high
This report
“Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the statutory agencies and private sector.”
Later report
“In the course of the evidence it was confirmed that there is no sharing of medical notes between private practitioners and NHS providers.”
Responses
2019-0499-Response-from-Camino-Healthcare-Redacted.pdf ↗· Camino Healthcare
2019-0499-Response-from-CQC-Redacted.pdf ↗· Care Quality Commission