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Allan Joslin

Ref: 2019-0241 Date: 17 Jul 2019 Coroner: Lydia Brown Area: Exeter and Greater Devon Responses identified: 1 / 1 View PDF

There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues and potential violence, leading to a lack of formal assessment and treatment, contravening equality legislation.

Date 17 Jul 2019
56-day deadline 16 Sep 2019
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues and potential violence, leading to a lack of formal assessment and treatment, contravening equality legislation.
View full coroner's concerns
The Devon Partnership NHS Trust had no adequate mental health care facility or safe room to deal with a patient who presented with complex needs including the need for mental health assessment; and drug and alcohol dependency issues, who was potentially violent There was no policy in place to facilitate the general practitioners' referrals and therefore Mr Joslin received no formal assessment or treatment prior to his death. This may have impacted on his ability to receive additional services and assistance with his homeless status. aged

Although this Trust have now put policies and facilities in place to treat patients presenting with a history of violence, it was clear evidence that this is a concern and difficulty in other Trusts across the country and is not a problem unique to Devon: While working with Devon to find a solution to the problem, NHS England confirmed this was problematic for a number of Trusts regarding provision of secondary care This is clearly a contravention of Equality legislation for those most vulnerable in society.

Responses

1 respondent
NHS England NHS / Health Body
PDF
Noted

The response contains no content. (AI summary)

View full response
11

Report sections

Investigation and inquest
On 4th June 2018 commenced an investigation into the death of Allan Graham Joslin
44. The investigation concluded at the end of the inquest on 17 April 2019. Medical Cause of Death: Ia) Dihydrocodeine and Pregabalin Intoxication Conclusion Drug-Related Death
Circumstances of the death
Allan was found deceased partially on top of a tent in the vicinity of the North Devon Leisure Centre, Barnstaple, on 23rd May 2018. He had not been seen or contacted by anyone for several days between the 18h May before the discovery of his body: Allan had been referred on two occasions by his general practitioners for a mental health assessment; but the local trust had no effective policy to facilitate this, given Allan's known previous violent behaviour. Neither assessment took place, missing an opportunity for Allan to be diagnosed and treated for his mental iIl-health and dependency on drugs and alcohol. Allan did not receive an appropriate service in accordance with his needs and presenting vulnerabilities_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action

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Related inquiry recommendations

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Southport Inquiry Community mental health services for violence-fixated children Southport Inquiry Mental health assessment powers for isolated children Muckamore Abbey Inquiry Blue light protocol for at-risk registers Brook House Inquiry Independent review of use of force on mentally ill detainees Manchester Arena Inquiry Healthcare provision under Protect Duty Manchester Arena Inquiry Review procedures for patient dispatch to hospitals

Report details

Reference
2019-0241
Date of report
17 July 2019
Coroner
Lydia Brown
Coroner area
Exeter and Greater Devon

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: 16 Sep 2019.

Sent to

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.