William Abel
20 Oct 2015 · Coroner Lydia Brown · Leicester City and Leicestershire South
The coroner's concerns
1. non-compliance with medication and missed appointments leading to suicide risk
“Mr [name redacted] had a diagnosis of paranoid schizophrenia and he was still under the care of the Mental Health services at the time he was found in the vicinity of the railway lines, expressing suicidal intention. He had missed appointments and there was a history of non-compliance with medication. Staff were available to have conducted a Mental Health Act assessment, on the night he was safely escorted from the railway lines, but this was not done.”
2. inadequate communication with family about mental health relapse and discharge planning
“Mr [name redacted] was discharged into the care of his father, and inadequate communications were made with the family, as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping. No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night.”
3. non-compliance with NICE guideline on family involvement in care
“NICE guidelines (Clinical guidance 136) state that health care professionals should discuss whether the patient would like the family to be involved in their care, and to provide them with information to understand the mental health problem and its treatments. This guideline does not appear to have been met in this case.”
Responses
2015-0406-Response-by-Leicester-Partnership-NHS-Trust.pdf ↗· Leicestershire Partnership NHS Trust
Stated action · December 2015
“The nurse concerned is undergoing a detailed programme of reflective practice led by the service's Senior Matron. This will be fully completed by December 2015.”
Stated action · November 2015
“The protocol for Mental Health Practitioners working with the Triage Car is being revised so that where there are clear indicators which prompt a discussion with a patient about the possibility of an admission to an Acute Hospital and a patient refuses to consider an informal admission, a Mental Health Act Assessment will be considered. If the assessment is not undertaken, the reasons for this decision taken within the context of the patient's presentation and the circumstances of the contact”
Stated action · December 2015
“We will undertake an audit to monitor compliance of the revised protocol in December 2015 and report the audit and further actions to be taken in January 2016.”
Stated action · November 2015
“Family members' presence during an assessment will be documented and we will ensure they are offered the opportunity to give their views, observations and understanding in relation to the crisis and the support required of them by the individual.”
Stated action · December 2015 for Triage Car, January 2015 for Crisis Team
“The service is introducing an outcome of assessment and plan record form to support the routine work of the Triage Car and Crisis Teams, ensuring that all patients come into contact with the Triage Car Mental Health Practitioner team are given key written information clarifying the immediate advice given, and where and how to access help should they need it.”