Source · Prevention of Future Deaths

Ernest Smith

Ref: 2017-0459 Date: 14 Dec 2017 Coroner: Anna Crawford Area: Surrey 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryConcerns persist regarding the system for considering GP correspondence, including medication review requests, which remains unchanged. Additionally, there is no clear system for updating GPs on patient progress or disengagement when care is led by non-medical multidisciplinary teams.

Date 14 Dec 2017

56-day deadline 8 Feb 2018 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Concerns persist regarding the system for considering GP correspondence, including medication review requests, which remains unchanged. Additionally, there is no clear system for updating GPs on patient progress or disengagement when care is led by non-medical multidisciplinary teams.

View full coroner's concerns

Following Mr Smith’s death a Root Cause Analysis investigation was conducted by the Trust and the court was told that a number of changes have been introduced and that further training has been provided. However, there remain two broad areas of concern.

The system for considering correspondence received from GPs, including requests for medication reviews, appears to remain the same as the system which was in place at the time of Mr Smith’s death and which failed to identify request for a medical review on 7 March 2016.
- There are a number of CMHRS service users who, like Mr Smith, are not under the CMHRS medical team, but whose care is led by other members of the multi-disciplinary team, including clinical psychologists and care co-ordinators. The court heard that there is a clear system in place in the medical team for updating GPs on progress and also in the event of failures to attend appointments (DNAs). However, it did not appear to the court that there was a clear system for updating GPs when the medical team was not involved in a patient’s care. This risks GPs being unaware, as was in this inquest, of instances in which their patient begins to display signs of disengagement with the service.

Consideration should be given to whether any steps can be taken to address the above concerns.

Responses

1 respondent

Surrey NHS Trust

NHS Trust

Indexed date: 28 Feb 2018 PDF

AI-classified response stance Action Planned

AI-generated response summary

• The Trust's Adult Mental Health Division created an action plan to address the concerns. • The action plan will be monitored at monthly Adult Mental Health Directorate Quality Assurance Group meetings. • The action plan will be shared with other service Divisions to apply learning across the Trust.

View full response

Dear Crawford Ernest Wayne Smith (deceased) Regulation 28 Report to Prevent Future Deaths (PFD) am writing further to the PFD report that you sent to Surrey and Borders Partnership NHS Foundation Trust (the Trust) in relation to Mr Ernest Smith, who sadly died on 13th June 2016. Thank you for taking the time to investigate his death so thoroughly and for bringing the matters of concern you have about the Trust's practices to our attention: The PFD report has been carefully considered and discussed by the Trust's Adult Mental Health Division, within which the Community Mental Health Recovery Services are located The Division has created the attached action plan, which outlines the actions that the Division is going to take in order to address your concerns_ hope the action plan is self explanatory. The action plan is going to be monitored and followed up at the monthly Adult Mental Health Directorate Quality Assurance Group meeting, which is attended by the Director and the Associate Medical Director for the Division In addition to the action plan will be shared with the other three service Divisions, to ensure that the learning can be applied and rolled out across the Trust as a whole_ Your PFD report was presented at the private Trust Board meeting in January 2018 and the action plan will also be submitted to the Board in due course_ On behalf of the Trust, would like to offer our sincere condolences to Mr Smith's relatives for their loss and hope that our action plan assures you and them that we have learnt and continue to learn his death: Please do not hesitate to contact me or Dr Justin Wilson, Chief Medical Officer; should you require any further information.

Report sections

Investigation and inquest

An inquest into the death of Ernest Smith was opened on 22 June 2016. It was resumed and concluded on 13 December 2017. The medical cause of death was found to be: 1a. Hanging

The inquest concluded with a short form conclusion of ‘Suicide’.

Circumstances of the death

On 13 June 2016 Mr Smith was found deceased in an area of woodland at Chelsham Common in Warlingham.

In 2011 Mr Smith had been diagnosed with depression and begun on anti-depressants by his GP, of Elizabeth House Medical Practice, Warlingham.

In April 2015 Mr Smith was referred to the Tandridge Community Mental Health Recovery Service (CMHRS) at Langley House in Oxted, which is part of Surrey and Borders Partnership NHS Foundation Trust (SABP).

In June 2015 Mr Smith was referred to , a Senior Clinical Psychologist at the CMHRS who saw him from August 2015 to May 2016. Mr Smith was also referred to the Enabling Independence Service and was provided with a Care Co-ordinator, but he did not engage with either.

Mr Smith’s GP remained responsible for prescribing his anti-depressant medication and continued to see Mr Smith regularly. gave evidence that she was concerned that he was not improving despite an increase to his anti-depressant medication.

On 31 July 2015 she contacted the CMHRS and requested that he be seen by a psychiatrist to review his medication. A medical review was arranged on 20 August 2015 but Mr Smith did not attend. was not informed that Mr Smith had been offered an appointment, or that he had not attended, and Mr Smith was not offered a further appointment, in contravention of the standard procedures in place at the time.

From March 2016 onward gave evidence that she had noticed a significant decline in Mr Smith’s presentation.

On 7 March 2016 she wrote to the CMHRS describing the deterioration and requesting a medication review. The court heard evidence that Dr Parry’s letter was considered at an Allocation Meeting on 15 March 2016, but did not result in a medical review. , the team’s Consultant Psychiatrist, accepted that Mr Smith ought to have been offered a medical review at that time but it was not possible to establish why it had not happened.

On 16 May 2016 telephoned directly and asked him to make an appointment for Mr Smith. agreed to do so but the appointment was not made prior to his death. It was not possible to establish exactly why the appointment was not made but it was most likely as the result of administrative error. gave evidence that she was not informed about numerous instances when Mr Smith either did not attend or cancelled appointments with , the Enabling Independence Service or his Care Co-ordinator.

Copies sent to

2. , Elizabeth House Medical Practice3. Care Quality CommissionSignedANNA CRAWFORDDATED this 14 day of December 2017

Similar PFD reports

Shared signals

Report details

Reference: 2017-0459
Date of report: 14 December 2017
Coroner: Anna Crawford
Coroner area: Surrey

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: 8 Feb 2018 (estimated from the report date).

Sent to

Surrey and Borders Partnership NHS Trust

Part of a series

2 reports

2024-0144 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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