Source · Prevention of Future Deaths

Katy Roberts

Ref: 2018-0136 Date: 27 Apr 2018 Coroner: L Tagliavini Area: London Inner (South) 1 response identified · 3 indexed addressees View PDF

AI-generated concerns summaryThe coroner notes a failure to communicate Care Plans and changes in writing, and a lack of clear routes for challenging these changes or for raising concerns in both emergency and non-emergency situations.

Date 27 Apr 2018

56-day deadline 26 Aug 2018 est. estimated from the Judiciary.uk publication date

Responses identified 1 of 3

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner notes a failure to communicate Care Plans and changes in writing, and a lack of clear routes for challenging these changes or for raising concerns in both emergency and non-emergency situations.

View full coroner's concerns

1) Failure to communicate in writing a Care Plan and changes to it (2)Failure to_provide a clear route _or opportunity to challenge or appeal these changes the Katy the Katy these to the Care Plan; (3) Failure to expressly communicate in writing all routes by which, to raise concerns and seek help on a non-emergency or emergency basis.

Responses

1 respondent

South London and Maudsley

NHS Trust

PDF

AI-classified response stance Action Planned

AI-generated response summary

• CAMHS community practitioners will ensure Community Care Plans are reviewed by young people and their families, with changes audited and reviewed quarterly. • Staff will be reminded to routinely provide written guidance, and a survey will be conducted to confirm its availability. • An Emergency and Developing Crisis Protocol has been established and shared with relevant parties.

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Dear writing

requirement in their monthly Performance Meetings and progress will be reviewed at the CAMHS Directorate Operational Governance meeting each Quarter: 2 Young Person's Engagement A striking element of the Coroner's finding was the extent to which, whilst there had evidently been good communications between professionals involved in Katy'$s care, there were opportunities missed to hear Katy's thoughts and views CAMHS community practitioners will ensure that the Community Care Plan proposed is reviewed by the Young Person and their family and then either agreed, or changed, within working weeks The number of Community Care Plans changed, following challenge or appeal will be audited and performance considered by CAMHS Directorate Operational Governance meeting each Quarter.
3. Guidance to Young People, their Parents Carers All CAMHS community services provide clear written guidance to Young People their families and other agencies on how to seek help from CAMHS and other services_ We will remind all staff to make this information available routinely and will conduct a survey with service user, carers and parents in January 2019 to assure the CAMHS Directorate operational management teams that the information is being made available_ Southwark now has an Emergency and Developing Crisis Protocol, which has been widely shared with GPs, schools counsellors, Young People and their families; copy is attached_

Report sections

Investigation and inquest

On 11/10/2017 an investigation was opened into the death of Katy Roberts aged 16. The investigation concluded at the end of the inquest on 12/04/2018. The conclusion of the inquest was suicide.

Circumstances of the death

Several years before her death; was diagnosed with Asperger's Syndrome, PTSD with a history of Anxiety, Depression and an eating disorder and was under the care of Child and Adolescent Mental Health Service (CAMHS) at SLAM at the time of her death In around May 2017 , the care plan that had been formulated and notified to Katy in writing was significantly altered. Although this change was communicated orally to and her family, it was not confirmed in writing and little, if any opportunity was provided to appeal this decision to alter Katy's care plan , despite the family's increasing concerns over its appropriateness for Katy. Consequently, at the time of her death Katy was under care plan believed by the family to be unsuitable for her; thereby exacerbating a breakdown of trust on the part of Katy's family in the service provided by CAMHSISLAM and creating a lack of provision for care or advice when a crisis, due to unexpected circumstances arose_

Similar PFD reports

Shared signals

Report details

Reference: 2018-0136
Date of report: 27 April 2018
Coroner: L Tagliavini
Coroner area: London Inner (South)

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 Aug 2018 (estimated from the Judiciary.uk publication date).

Sent to

South London & Maudsley NHS Trust

Southwark Safeguarding Children Board

Steel & Shamash Solicitors

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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