Tom Sweeting
9 Jan 2024 · Coroner Lydia Brown · West London
The coroner's concerns
1. non-completion of Trust template for mental health assessment
“[the deceased] was assessed in relation to his mental ill health presentation by the Consultant liaison psychiatrist, but the Trust template was not completed, which was not in compliance with the Trust policy and criticised in the Trust serious incident report”
2. delayed or absent discharge letters
“No letter of discharge was sent at the time [the deceased] was seen by the liaison psychiatry team, and a letter was only generated in response to investigations taking place after the death”
3. delegation of critical family information to junior staff
“It was acknowledged that obtaining collateral information from the family is vital, but in this case was delegated to a very Junior member of the team who was in the early stages of her training”
4. lack of evidence for training programme effectiveness
“The Trust showed good intentions of reviewing the training programme, but were unable to evidence that planned 6 monthly audits had actually taken place”