Bryan and Mary Andrews

There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.

ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.

iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.

iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.

v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.

vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.

vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.

viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.

ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.

x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.

The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.