Lewis Colgan

(1) It was clear from the evidence that the role of the care coordinator is very important in terms of engagement with patients, conducting risk assessments, coordinating necessary or periodic meetings and providing regular input to the care team: In Lewis' case the evidence indicated that the last care coordinator with conduct of his case had not received supervision, that the caseload was, for a period, incompatible with part time working, and that the frequency of engagement with Lewis had reduced compared with what had occurred in previous years_ There were also concerns about upward supervision of the care team during this period. Whilst evidence was given that the supervision arrangements are addressed, there remain concerns that supervision within teams and cross-supervision between teams, particularly of the critical role and caseload of care coordinator; may still lack robustness (2) Lewis' mental health care revealed issues with regard to management of staff changes and sickness and particularly coordination of continuity of engagement and care in the context of Lewis' care plan in the absence of key participants in his care on long term sick leave, notably the roles of care coordinator and psychologist and, notwithstanding evidence indicating steps taken to address staffing issues, there remains a concern that; given the personal nature of the mental health care provided to individuals and the significance of regular engagement with specific individuals, that provision of care in compliance with specified care plans may be compromised: (3) There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these Evidence given the Inquest from different Trust witnesses appeared to identify a difference of opinion as regards what the policy was for frequency of CPA meetings. A concern exists regarding knowledge of what the current policy is and how it is being applied.

(4) Whilst a Root Cause Analysis had been undertaken and a report provided, there were concerns raised during the Inquest with regard to staff training, which the report did not address, and the last care coordinator with conduct of Lewis' case was not able to participate in the investigation, nor the Inquest: The report did not include an ongoing action to engage with that care coordinator in order to fully address the issues raised in that investigation. As a result; there remains an ongoing concern about the robustness of the investigation and actions identified: Coroner' $ Office; 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 2JJ Tel: (01494) 475 505 Fax: (01494) 673 760 E Mail: coroners@buckscc gov.uk being being during

C.GBUTLER