Terence Pimm
14 Aug 2017 · Coroner Caroline Beasley-Murray · Essex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate call handling and record-keeping
“Call handling and record-keeping at The Lakes”
2. inadequate call handling and record-keeping
“Call handling and record-keeping at the police custody suite”
3. insufficient guidance and training
“The sufficiency of guidance and training”
4. uncertain risk assessment by police call handlers
“To police call handlers as to whether an individual is, objectively, at an "immediate" risk”
5. insufficient family involvement in assessments
“To mental health assessors as to the circumstances in which the input of family Members should be sought”
6. poor information sharing and coordination
“The sufficiency of information sharing and coordination between the police, hospital Trust and probation service”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.”
Later report
“Essex Police were aware that [the deceased] was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime.”
Responses
2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted.pdf ↗· EPUT
Stated action
“All health-based place of safety calls are directed now through the new Trust's call centre. This means that all calls are recorded and documented on a call-log by trained call-handlers.”
Stated action
“All patients admitted to health-based places of safety have individual patient records detailing potential risks, assessment of presentation and copies of documentation from other agencies. Further work is continuing on electronic record-keeping processes in regard to this issue.”
Stated action
“The new Trust has taken steps to reinforce to staff the importance of family involvement and ongoing communications. A detailed debrief in this respect was undertaken with the staff involved in Mr [name redacted] care. Additionally, audits on this issue are being undertaken via the new Trust's staff supervision process.”
Stated action
“The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard.”
Stated action
“The new Trust has launched a new street-triage team in which mental health practitioners work together with dedicated police officers. We anticipate that this initiative will also help significantly to improve information-sharing and coordination between our services.”
Stated action
“A new flowchart is in place now for staff, which details clearly which actions to take in situations where people are subject to a warrant. Training on this is underway for all our staff working in mental health accident and emergency teams and mental health criminal justice teams.”
2017-0217-Response-by-Essex-Police.pdf ↗· Essex Police
Stated action · 1° September
“Essex Police have taken the following action; e Essex Police has written to the Essex and Essex Community Rehabilitation Company concerning the outcome of the Inquest;”