Sian Witheridge
23 Oct 2017 · Coroner ME Hassell · London Inner (North)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of mental health records for OneHousing staff
“While Ms [name redacted] was staying in Crisis House, her mental health records were not available to the OneHousing staff there.”
2. inadequate written risk assessment
“I was told that the written risk assessment provided to Highbury Grove Crisis House was not as detailed as it should have been.”
3. limited historical record review
“health records, but they did not read them any further back than the date of her first call to crisis house during that last episode, i.e. 25 May 2017, despite her very extensive past medical history. There”
4. unenforceable risk assessment plan
“One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms [name redacted] took any leave. However, this was an unenforceable plan, because Highbury Grove is an open facility.”
5. misinterpretation of suicide plan response
“There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.”
6. disjointed care coordination
“The care offered to service users of Highbury Grove Crisis House and the Islington Crisis Team seemed disjointed and not dovetailed between OneHousing and Camden & Islington NHS Trust.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The doctor did not ask Ms [name redacted] about thoughts of suicide within the context of her earlier declaration that she would die that night.”
This report
“There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.”
Closely relatedConfidence 0.85 · high
Earlier report
“The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist.”
This report
“One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms [name redacted] took any leave. However, this was an unenforceable plan, because Highbury Grove is an open facility.”
Responses
2017-0305-Response.pdf ↗· One Housing Group
Stated action · early 2018
“we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.”