Thomas Thurling
6 Aug 2015 · Coroner Jacqueline Lake · Norfolk
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of medication monitoring
“On 13 August 2014 Mr [name redacted] medication was changed to help his low mood and anxiety. The Psychiatrist specifically stated that the change in medication was to be monitored to include the involvement of the CRHT Team. One Psychiatrist gave evidence (which was read) that the change in medication was closely monitored by - Mind.”
2. absence of care coordinator without replacement
“Care Co-ordinator was on planned and unplanned leave from end September 2014 until time of Mr [name redacted] death. Her Line Managers were aware of this continuous absence. Prior to this there had been a general deterioration in Mr [name redacted] mental health noted, he was clearly expressing suicidal ideation, He had attended A & E with thoughts of suicide and he had bought a penknife and cut his neck. His mother had contacted MH Team expressing her concerns on at least 2 occasions.”
3. staff shortage at Trust
“Itis clear from evidence given at the inquest that there is a shortage of staff at the Trust. Steps are being taken to try and address this but it is unclear as to what is being done in the meantime to cope with the difficulties that arise as a result.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“On 12 August 2014 Psychiatrist recommended Mr [name redacted] would benefit from a Support Worker and/or Care Co-Ordinator - this was not actioned”
This report
“Care Co-ordinator was on planned and unplanned leave from end September 2014 until time of Mr [name redacted] death. Her Line Managers were aware of this continuous absence”
Responses
2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust.pdf ↗· Norfolk and Suffolk NHS Foundation Trust
Stated action
“The Trust recognises that changes in medication are a significant stage in an individual's treatman and require monitoring in order to ensure it is having anticipated effects and be ready to respond, to possible side effects.”
Stated action
“the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e. a colleague completing visits and contacts.”
Stated action
“The Trust is taking active steps to recruit to these areas but we have found our experiences and challenges are shared across the health sector. The Trust is taking steps to mitigate the risks by employing temporary staffing for defined periods of time.”