Source · Prevention of Future Deaths

Conall Gould

Ref: 2017-0458 Date: 28 Sep 2017 Coroner: Emma Brown Area: Birmingham and Solihull Responses identified: 1 / 1 View PDF

The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust lacked a policy requiring written confirmation. This created a significant risk of missed appointments and inadequate care review.

Date 28 Sep 2017

56-day deadline 23 Nov 2017 est.

Responses identified 1 of 1

Mental Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

At the time of discharge from Holywell Hospital on the 30th January 2017 Mr: Gould had been referred to the community mental health team for a 7 day review and had been given an appointment on the 2"d February 2017. There is no evidence in the Trust'$ records that the time, date and location of this appointment was given to Conall or his parents_ The evidence 0= [Consultant Psychiatrist; who saw Conall and his father on the 30"h January 2017 was that he anticipated that the discharge nurse would tell Conall and his mother or father, as his carers, the date of his review at the point of discharge as this is the usual practice_ Mr. Gould; Conall's father, gave evidence that not only were he and his wife not told verbally of the appointment nor were they given any written information about it: on a previous discharge from an inpatient stay at another Trust had been given a letter setting out the appointment arrangements for his son following discharge_ Conall was 21 at the time of his discharge on the 30" January and his parents had taken a very active role in his care: If they had been aware of the appointment they would have made every effort to secure Conall' s attendance, as it was,believing there_to be no plan for follow Up,they did not prevent him from day being travelling to Birmingham for a period ofrest with relatives (during which time he took the fatal overdose of MDMA) The evidence of who conducted the RCA was that the Trust does not have protocol or policy stipulating the arrangements for notifying services users and their carers of follow up arrangements on discharge and current practice does not require written confirmation of follow up arrangements to be given to the service user or their carers The system currently creates a risk that services users and their carers will not be aware of follow up appointments and therefore may not attend giving rise to a danger that opportunities to review the service user' $ condition and treatment will be lost_

Responses

1 respondent

Conall Patrick

26 Mar 2018 PDF

Action Taken

The Northern Health and Social Care Trust has introduced a requirement for written confirmation of follow-up appointments and contact numbers to be provided to patients and, with consent, their relatives/concerned others upon discharge from hospital, documented in the Integrated Care Protocol. (AI summary)

View full response

Dear Ms Hunt Mr Conall Patrick Gould Inquest held on 26 September 2017, Regulation 28 Report to Prevent Further Deaths Firstly, please accept my sincere apologies for the delay in this response to you: In relation to the matters of concern raised by you during the Inquest held into Conall's death, can now inform you of the actions the Trust has made to strengthen systems and processes of care to support patients and their families on discharge from hospital. The Trust has introduced into the Integrated Care Protocol (the in-patient clinical documentation record of the multi-disciplinary treatment team) a requirement for all patients, when being discharged from hospital, to receive written confirmation of their 7 follow-up appointment with relevant telephone contact numbers if they require assistance in the immediate days following discharge; This protocol also directs that a relativelconcerned other, identified by the patient; will also be provided with this written information when consent to do so has been given by the patient: Under the heading 'Discharge Process' on p5 section 3 has been amended in reference to the information given to the patient on discharge and section 4 has been added in reference to the carer and the information that should be shared with them, with the agreement of the patient In addition, on page 78, the Discharge Care Plan has been amended significantly to ensure both the patient and, if acceptable to the patient; the carer; are given a copy of the Discharge Care plan, Support plan and list of medication. The Trust believes this action adds a level of robustness to the existing discharge processes and addresses the concerns raised and have attached templates of the documentation now provided to all patients. would wish to thank you for raising this matter and would also advise it is planned that this protocol will be shared with Trusts across Northern Ireland at a workshop to be held on 6 June 2018, Trust Headquarters, Bretten Hall, Antrim Area Hospital, Bush Road, Antrim BT41 2RL Phone: 028 9442 4321 Email: oscar donnelly@northerntrust hscni net Ms day

Report sections

Investigation and inquest

On 23/05/2017 commenced an investigation into the death of Conall Patrick Gould: The investigation concluded at the end of an inquest on 26th September 2017. The conclusion of the inquest was that Mr. Gould' s death was drug related:

Circumstances of the death

Conall Patrick Gould died on the 13th February 2017 at the Queen Elizabeth Hospital in Birmingham having been admitted earlier that after witnessed to behave erratically and then collapse: Conall had a diagnosis of a delusional disorder, for which he had received inpatient treatment; and a history of drug: When last reviewed prior to discharge from inpatient psychiatric care at Holywell Hospital on the 3Oth January 2017 he had maintained a positive outlook and insisted that his most recent overdose was recreational and without any intention to cause himself harm. Following his discharge his behaviour did not give his family cause for concern that he would attempt suicide: Following a post mortem the medical cause of death was determined to be: 1 (a) ECSTACY USE

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0458
Date of report: 28 September 2017
Coroner: Emma Brown
Coroner area: Birmingham and Solihull

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: 23 Nov 2017 (estimated).

Sent to

Northern Health and Social Care Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.