Sofia Legg
4 Oct 2017 · Coroner Tony Williams · Somerset
The coroner's concerns
1. lack of timely mental health referral
“Access to CAMHS. [the deceased] was rejected for referral in April 2015. Might a lower threshold and earlier proactive interventionist policy has been of positive benefits to [the deceased].”
2. prolonged CBT waiting list
“Availability of CBT. [the deceased] was placed on a 6 month waiting list for CBT. This delay appears considerable.”
3. failure to involve psychiatrist urgently
“[the deceased]'s care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance.”
4. inadequate safety planning
“The recollections of [the deceased]'s care co-ordinator and [the deceased]'s mother as to the meeting of the 19"" September were at odds with each other. [the deceased]'s care co-ordinator recollected in her evidence telling [the deceased]'s mother that [the deceased] was not to be left alone. [the deceased]'s mother deemed the impression from [the deceased]'s care co-ordinator's evidence was of [the deceased] being an extremely vulnerable and dangerous position abut this was not reflected in [the deceased]'s care plan which made no mention of her not being left alone and it was”
5. misleading report conclusions
“Language used in the SIRI Report was felt to be inappropriate. The SIRI Report effectively said if the care plan had been followed the outcome might have been different and that no change in clinical practice would have resulted in any different outcome. | do not believe either of these statements were true.”