Source · Prevention of Future Deaths

Noah Lomax

Ref: 2019-0186 Date: 24 May 2019 Coroner: Angharad Davies Area: South Yorkshire (West) Responses identified: 1 / 1 View PDF

The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.

Date 24 May 2019
56-day deadline 9 Oct 2019 est.
Responses identified 1 of 1
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.
View full coroner's concerns
1. As I made clear during the Inquest I was concerned about the adequacy of the CAMHS, GP referral form. , Noah’s GP, was inexperienced she had not completed a CAMHS referral form before. She accepted that she had not provided sufficient detail in the form. This resulted in CAMHS being unable to assess Noah’s risk and declining Noah’s referral. This in turn meant that Noah did not receive an appointment with CAMHS before his death.

The Trust’s investigation report stated that the evidence “suggests that the current referral form does not capture the information required to process referrals without delay.”

, CAMHS Clinical Lead, said that there had not been any other problems with the form with GP’s not completing them sufficiently. I am not sure how is able to be so confident about this.

I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form.

Having carefully considered the evidence I am not satisfied that steps have been put in place to ameliorate the risk identified. Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided. I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care.

Responses

1 respondent
Sheffields Childrens NHS Trust NHS / Health Body
27 Jun 2019 PDF
Action Planned

The CAMHS team has commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning at Sheffield Clinical Commissioning Group (SCCG) for comments. The reviewed and updated form and guidance will be distributed to all General Practitioners by 12 July 2019. (AI summary)

View full response
Dear Ms Davies Noah Lomax (deceased) Regulation 28 write in response to your Regulation 28 Report to Prevent Future Deaths dated 24
2019. Under paragraph 7 Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust to consider your matter for concern and take action to prevent future deaths. The Trust sets out below its response to your matter of concern below: During the inquest into the death of Noah Lomax you expressed concerns about the adequacy of the CAMHS referral form that is used by General Practitioners You identified that our investigation report stated that the evidence 'suggests that the current referral form does not capture the information required to process referrals without delay' and that during the inquest you heard evidence that there had not been any other problems with GP's not completing them sufficiently and that redesigning the form had been considered by the Trust but was told this was not the answer. You were informed further training had been provided to General Practitioners and guidance had been attached to the referral forms to assist General Practitioners with this process_ The actions described above did not assure you that satisfactory steps have been in place to ameliorate the risk identified. You have therefore invited our Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided, which may result in a in care_ During the inquest it was confirmed that the referral guidelines were being updated with input from a General Practitioner, This has now been completed and the guidance is now in place and used. The current form will continue to be used alongside the new guidance in mitigation until the actions outlined below have been completed. The CAMHS team have commenced a review of the referral form_ and a draft form was sent to the Clinical Director for Mental Health commissioning the Sheffield Clinical Commissioning Group (SCCG), for comments This draft was reviewed by SCCG's Clinical Reference Group, which The togetriur John Somers SVS Stoetfietder ciedstsi Sarah Jones Chief Executive Stundard Chair charirv: ~urt Your May put delay being

consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form: Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners The form and guidance are currently reviewed and updated and will be distributed to all General Practitioners by 12
2019. If can be of any further assistance please do not hesitate to contact me_

Report sections

Investigation and inquest
An investigation was commenced into Noah Lomax’s death on 8 August 2018 and an Inquest was opened the same day.

I concluded an inquest on 24 May 2015.

The findings of the court were as follows:

Medical Cause of death 1(a) Multiple Injuries

Conclusion: Suicide
Circumstances of the death
Noah was 15 years of age. At the beginning of July 2018 Noah’s mother was made aware of online communication between Noah and a friend in which he expressed an intention to take his own life by jumping off a bridge. Noah’s mother acted immediately upon this concern and both made an appointment for Noah to see his GP and to attend Door43 an organisation that provides emotional support for young people.

Noah’s and his mother attended the GP appointment with the specific intention to obtain help by way of a referral to CAMHS. Noah’s GP was told that he had suicidal thoughts and had plans to take his own life. Noah’s GP completed a written, non-urgent, referral to CAMHS

CAMHS processed the referral promptly but the referral contained insufficient information for a risk assessment to be performed Therefore, CAMHS closed

Noah’s referral but invited his GP to provide further information. Noah’s GP planned to use the appointment arranged on 6 August 2018 as an opportunity to obtain the further information sought by CAMHS.

Noah’s family were not notified that CAMHS had declined the referral. The Trust accepted that the process of requesting further information was not sufficiently robust and that telephone contact with the GP should have been made. This would have avoided the need for a re-referral. Had the information been known that Noah was actively making plans to take his own life CAMHS would have categorised his appointment as urgent and seen him within 2 weeks.

Assumptions were made regarding the support being offered to Noah by Door43. The Trust accepted that the actual level of support ought to have been confirmed directly between CAMHS and Door43.

The Trust accepted that the current referral form does not capture the information required to process referrals without delay.

Noah went on holiday with his father and step-mother between 22 July and 29 July 2018. Noah was not seen by CAMHS on his return.

On 1 August 2018 Noah was not open with his mother about his plans. Instead of spending the day with friends he travelled, by a pre-planned route, to Conisborough Viaduct. Sometime after 1.30pm Noah took his own life by jumping from the Viaduct.

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Report details

Reference
2019-0186
Date of report
24 May 2019
Coroner
Angharad Davies
Coroner area
South Yorkshire (West)

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: 9 Oct 2019 (estimated).

Sent to

Sheffield Children’s NHS Trust

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