Teresa Chmielek
24 Nov 2023 · Coroner Catherine McKenna · Manchester North
The coroner's concerns
1. risk of suicide not identified or recognised
“The notes made by the SPoE Nurse for use during discussion at the screening MDT meeting did not include any reference to the report of a recent suicide attempt and the Court was not satisfied that the risk of suicide had been identified or recognised by the SPoE Nurse”
2. lack of direct contact with patient before referral rejection
“There was no direct contact between the mental health team and the Deceased (either by telephone or in person) before the decision to reject the referral was made”
3. absence of standard operating procedure for referral management
“There is currently no Standard Operating Procedure on how referrals into the SPoE Older Adults should be managed”
4. lack of audit system for referral management and decision-making
“There is currently no system by which the management of referrals into the SPoE and related decision-making are audited. As such there is a risk that poor quality decision-making is going unchecked”