Source · Prevention of Future Deaths

Samuel Morgan

Ref: 2023-0163 Date: 18 May 2023 Coroner: Kirsten Heaven Area: Swansea Neath Port Talbot Responses identified: 1 / 1 View PDF

A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses a significant risk that critical patient safety information will be lost between agencies.

Date 18 May 2023

56-day deadline 13 Jul 2023

Responses identified 1 of 1

Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

During the inquest the evidence revealed matters giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013

The first MATTERS OF CONCERN is as follows:

I am concerned that in cases where an individual is receiving treatment from alcohol and drug addiction services and treatment from the primary community mental health team that neither team is able to access the other teams records electronically. The lack of integrated electronic records between treating team means that important information regarding patient safety is not easily accessible between treating teams. Treating teams are reliant on referral letters which are necessarily limited and not always sufficient to capture all the detailed information available to a referring team. This is particularly concerning where there is dual diagnosis - such as substance misuse and mental health - given these are often complex cases. This is particularly the case where complex cases have not been referred into secondary mental health services and so do not have access to a care-coordinator who can oversee and understand the views of the various professionals treating and assisting an individual.

I am concerned that the lack of such an integrated electronic system of medical and treatment records inhibits the effective sharing of information regarding patient safety and so increases the risk that information of significance regarding a risk to life will be lost between agencies and not sufficiently understood between all those managing risk.

Responses

1 respondent

Swansea Bay University Health Board NHS / Health Body

12 Jul 2023 PDF

Action Planned

For Swansea based teams, technical changes to enable two-way information sharing between community mental health teams and drug and alcohol services via WCCIS will be completed within 10 working days, commencing 7th August 2023. For NPT based teams, access to WCCIS on a read-only basis will be extended, with implementation planned from 4th September 2023. (AI summary)

View full response

Dear Ms Heaven, RE: REGULATION 28: REPORT TO PREVENT FUTURE DEATHS I write in response to the matter of concern raised in respect of the deceased Mr Samuel Morgan. The Health Board fully acknowledges the concerns you have raised and understands the importance of sharing information between the Community Mental Health Teams (CMHT) and the Community Drug and Alcohol Team (COAT) to improve patient safety and outcomes. The solution to this is intended to be the implementation of the Welsh Community Care Information System, (WCCIS) which is a national IT programme aimed at enabling the safe sharing of information between health and social care. This has been partially rolled out within the Health Board as part of the implementation of the solution within Swansea Local Authority. Further roll out within the Health Board is currently on hold pending the approval by Welsh Government of recommendations made within a Ministerial Advice Paper presented by the National Programme Team. The situation is complicated by the fact that only one of our Local Authority partners has chosen to implement WCCIS. The current deployment of the solution within SBUHB is managed by Swansea Local Authority who Bwrdd lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board

grant licenses to Swansea Bay staff. Any amendments to system functionality have to be requested and implemented by the Local Authority. The Health Board recognises the need to take urgent action to address the issues that have been identified and understands that this cannot wait for the further development/roll out of WCCIS. The following actions will therefore be taken:
1. For Swansea based teams there is opportunity to share information between community mental health teams and drug and alcohol services via WCCIS which will allow 2 way sharing of all information in the WCCIS system relating to episodes of care both within community mental health services and drug and alcohol services. The technical changes to enable this will be completed within 10 working days and it is intended that this will be implemented week commencing 7th August 2023.
2. For NPT based teams and LPMHSS the Health Board will extend access to WCCIS on a read only basis supported by a Standard Operating Protocol (SOP) for staff which requires them to search WCCIS for episodes of care when patients enter and move through the service. Staff will also be able to upload clinical records to the system which will enable information sharing with other community based services. It is intended that this will be implemented as from Monday 4th September 2023. I am confident that the changes described above address your concern, however please do not hesitate to contact me if you require any further information

Report sections

Investigation and inquest

On 13th May 2019 an investigation was commenced into the death of Samuel Alexander Morgan who was found deceased in his parents’ house on the 9th May 2019 after having tied a ligature around his neck. He was 29 years of age at the time of his death. The investigation concluded at the end of the inquest on 6th March 2023. The medical cause of death was: 1a Hanging

Circumstances of the death

The deceased was Samuel Alexander Morgan At the time of his death Samuel was suffering from alcohol addiction and had a diagnosis of ADHD and social anxiety. Prior to his death Samuel had received treatment from the Community Drug and Alcohol Treatment (‘CDAT’) team and primary mental health services. Samuel was discharged from CDAT fifteen months prior to his death. CDAT had information on their system (including from their own risk assessment) to indicate that Samuel had been assessed as a significant risk of suicide. There was other valuable information about Samuel’s risk factors on the CDAT system. At the time when Samuel was under CDAT the GP had also referred Samuel to the community mental health team raising his concerns about Samuel’s risk of suicide. It is not clear is CDAT had access to this letter. When the primary mental health services consultant began treating Samuel for his ADHD - which continued up to Samuel’s death - he received a referral from CDAT but he did not have access to the detailed information on the CDAT electronic system. The consultant could not and did not see the CDAT risk assessment, the outcome and assessment from the individual CDAT sessions and other vital historical information of potential relevance to Samuel’s risk factors and triggers for suicide.

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Report details

Reference: 2023-0163
Date of report: 18 May 2023
Coroner: Kirsten Heaven
Coroner area: Swansea Neath Port Talbot

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Jul 2023.

Sent to

Swansea Bay University Health Board

Part of a series

2 reports

2020-0276 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.