Stephanie Moyce
25 Feb 2022 · Coroner Sean Horstead · Essex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of discharge plan responsibility
“Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated for those coming to the end of a course of psychotherapy where a Care Coordinator is no longer in place/has not been replaced”
2. lack of post-discharge oversight
“Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff has the responsibility for oversight of patient care following discharge, including responsibility for ensuring adequate and appropriate safety- netting is in place in the event of relapse, where a Care Coordinator is no longer in place/has not been replaced”
3. missed multidisciplinary team discussion
“patients under psychotherapy are not presently routinely discussed in the locality multi-disciplinary team meetings prior to their 2 discharge leading to a missed opportunity: (a) to share information about the specific progress, vulnerabilities and risks of relapse of the patient (and measures to mitigate or deal with the same); as well as (b) to organise and follow up the overall discharge planning”
4. carer not treated as equal partner in after-care plans
“The evidence in this case indicated that, contrary to EPUT's own established Protocol, a patient's carer (in this case her long-term partner where no confidentiality issues were identified) are not in practice always”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated”
Later report
“(d) Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy.”
Responses
No published response was found on judiciary.uk.