Source · Prevention of Future Deaths

Grahame Searby

Ref: 2018-0162 Date: 23 May 2018 Coroner: Martin Fleming Area: West Yorkshire (West) Responses identified: 0 / 1 View PDF

The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.

Date 23 May 2018
56-day deadline 2 Sep 2018 est.
Responses identified 0 of 1
Community health care and emergency services related deaths Suicide (from 2015)

Coroner's concerns

AI summary
The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.
View full coroner's concerns
During the evidence and informed me that at the time of Mr Searby' s death; the mental health team did not have access to the system one database or EMIS for the purposes of referencing the GP s database: Although I was told that access via the system one data base is currently in operation, there is still no access to the appropriate date via EMIS The MATTER OF CONCERN is as follows: To review the existing operational systems and to consider the appropriateness of facilitating access via EMIS in order to improve the information gathering process. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and [ believe that South West Yorkshire Partnership NHS Foundation Trust the has the power to take such action: RT3589 history police from

YOUR RESPONSE You are under a duty to respond to this report within 56 of its date; I may extend that on request Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed: COPIES Ihave sent a cOpY of this report to: daughter Chief Coroner DATED this 23/5/18 IDFi2e RT3589 days . period

Report sections

Investigation and inquest
On 2/8/17 I opened an inquest into the death of Grahame Searby who, at the date of his death was 59 years. The inquest was resumed and concluded on 15th 2018 Ifound that the cause of death to be: la. Hanging Iarrived at the following narrative conclusion: On 27*h July 2017 Grahame Searby, who suffered from extreme anxiety and depression, was found hanging from & rope attached to a joist at the top of the stairs at his home address It is found that he intended his death: Atthe time of his death he was under the supervision of the mental health services in the community, and although there was &n opportunity to admit him to hospital, it remains unclear whether it would have made a difference to the outcome: RT3589 aged May ceiling_

CIRCUMSTANCES OF DEATH Mr Searby had a of suffering from extreme anxiety and depression for which he was under the auspices of his GP and MHS_ When he failed to attend his medical review appointment on 27/7/17 as expected, his community Psychiatric Nurse made several unsuccessful attempts to contact him by phone before attending at his home address to find no response: This resulted in the attendance of the in order to conduct a welfare check; and it was then that Mr Searby was to have died by hanging: At the inquest evidence was heard Mr Searby' s mental health team including land Before he died Mr Searby was admitted to A&E on 20/7/17 and 23/7/17 in a state of extreme anxiety when he asked to be voluntarily admitted for treatment to hospital After risk assessment it was thought appropriate thathe be placed under the care of the Home based treatment team.

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Report details

Reference
2018-0162
Date of report
23 May 2018
Coroner
Martin Fleming
Coroner area
West Yorkshire (West)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Sep 2018 (estimated).

Sent to

South West Yorkshire NHS Trust

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