Source · Prevention of Future Deaths

George Rogers

Ref: 2019-0484 Date: 27 Nov 2019 Coroner: Joanne Andrews Area: West Sussex Responses identified: 1 / 1 View PDF

The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment and leaves patients unmonitored during a critical transition period.

Date 27 Nov 2019
56-day deadline 10 Jan 2020
Responses identified 1 of 1
Suicide (from 2015)

Coroner's concerns

AI summary
The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment and leaves patients unmonitored during a critical transition period.
View full coroner's concerns
1. When transferring patients between the CHRTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment.

Responses

1 respondent
Sussex Partnership NHS Foundation Trust NHS / Health Body
PDF
Action Taken

A new process was introduced to allocate a Lead Practitioner which resulted in a 95% reduction in unallocated patients at the point of transfer between teams. (AI summary)

View full response
Dear Ms Andrews Re. Inquest into the death of George Edward ROGERS I write further to the inquest of George Edward Rogers which concluded on 11.11.2019 and the Regulation 28 Report to Prevent Future Deaths. The Report concern is as follows:
1. When transferring patients between the CRHTT (Crisis Resolution and Home Treatment Team) and the ATS (Assessment and Treatment Service) there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patient may not be monitored pending appointment. I will address both points raised in turn, as follows: (a) Allocation of a Lead Practitioner of patients transferred from the CRHTT and ATS The process for allocation of a Lead Practitioner is as follows; the CRHTT attends the weekly Multi-Professional ATS meeting (ATS - sometimes referred to as a Community Mental Health Team) to provide an update on each case and to request allocation, if needed, of a Lead Practitioner. If the patient is already known to the team,·the Lead Practitioner (ATS) will remain involved and work with the CRHTT throughout the episode of care. If the person is unknown to the ATS, the CRHTT and ATS will work together to plan onward care and support. Where a Lead Practitioner cannot be provided immediately by the ATS, an initial appointment will be offered within 7 days of transfer from the CRHTT and follow-up plans will be agreed. This may include care and support being offered by the ATS Duty Worker (a senior registered professional) who the patient will be able to contact for support. This support includes face to face contact on the same day if necessary and attendance at the ATS if

Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP

A teaching trust of Brighton and Sussex Medical School

required. In this instance, the patient and the GP are sent a letter informing them of this plan of care which includes any contact details if there are any concerns. Any patient not allocated a Lead Practitioner is monitored by the Team Leader on a weekly basis. The SPFT Serious Incident report notes that a delay occurred in the allocation of a Lead Practitioner, over a two week period, in April 2018 when Mr Rogers was being transferred between the CRHTT and ATS. As a result of this a new process has been introduced as described above resulting in a 95% reduction in unallocated patients at the point of transfer between teams. I hope that the content of this letter and its enclosures addresses your concerns and provides you with assurance that there is no delay in a patient receiving access to treatment on transfer between CRHTT and the ATS, that there is a process in place to monitor patients who have been transferred and are receiving support with the Duty Worker whilst a Lead Practitioner is identified. However, ifany further clarification is required or I can assist further in any way then please do not hesitate to contact me.

Report sections

Investigation and inquest
On 11 September 2018 I commenced an investigation into the death of George Edward Rogers, 30. The investigation concluded at the end of the inquest on 11 November 2019. The conclusion of the inquest was that Mr Rogers died as a result of an intentional act by him take his own life by causing a fatal laceration to his chest. I therefore gave a conclusion of suicide.
Circumstances of the death
1. Mr Rogers had a diagnosis of body dysmorphic disorder. He was previously treated for the condition and recovered. He was resident in Australia in 2017 when he started to become unwell again with BDD and returned to the UK in February 2018.
2. On his return to the UK Mr Rogers’ parents took him to his GP who referred Mr Rogers to the Acute Treatment Service (ATS).
3. Before that referral could take effect Mr Rogers attempted to take his own life by causing a laceration to his chest which resulted in an admission to Southampton General Hospital. This was a life threatening injury.
4. On discharge from Southampton General Hospital on 23 February 2018 Mr Rogers was placed under the care of the Crisis Resolution and Home Treatment Team (CRHTT).
5. Mr Rogers was treated by the CRHTT until he was transferred to the care of the ATS on 9 April 2018. On transfer between CHRTT and ATS Mr Rogers was not appointed a Lead Practitioner to coordinate his care.
6. Mr Rogers was assessed by ATS on 11 April 2018. Mr Rogers heard nothing more from ATS until 23 April 2018 following his family’s intervention having heard nothing. A Lead Practitioner was appointed on 23 April 2018. Mr Rogers was not receiving treatment or being seen by ATS between 11 April 2018 and 14 May 2018 and had no treatment or ongoing assessment of risk during this period. It was accepted in evidence by Sussex Partnership NHS Trust that the lack of appointment of a Lead Practitioner for Mr Rogers resulted in delay in his treatment.
7. Mr Rogers received treatment from ATS up until his death on 28 August 2018.

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Report details

Reference
2019-0484
Date of report
27 November 2019
Coroner
Joanne Andrews
Coroner area
West Sussex

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: 10 Jan 2020.

Sent to

Sussex Partnership NHS Trust

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