Source · Prevention of Future Deaths
Leah Ratheram
Ref: 2017-0081
Date: 15 Mar 2017
Coroner: Louise Hunt
Area: Birmingham and Solihull
0 responses identified · 5 indexed addressees
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AI-generated concerns summaryThe coroner identified uncoordinated mental health care for young adults (18-25) in crisis, with unclear responsibility and ineffective information sharing between two service providers. Concerns also noted insufficient early involvement of approved social workers in Mental Health Act assessments.
Date
15 Mar 2017
56-day deadline
10 May 2017 est.
estimated from the report date
Responses identified
0 of 5
Coroner's concerns
The coroner identified uncoordinated mental health care for young adults (18-25) in crisis, with unclear responsibility and ineffective information sharing between two service providers. Concerns also noted insufficient early involvement of approved social workers in Mental Health Act assessments.
View full coroner's concerns
In the circumstances it is my statutory to report to you: Adults aged between 18 25 now have mental health services provided by two organisations Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust: If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust: If they require ongoing treatment they will be referred to forward Thinking Birmingham: There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient; particularly during the period of transfer. Both organisations use different record keeping systems There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process. It was unclear how staff from each organisation would access each other's records when patients present to one or other of the services: The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed: There is a concern that lack of involvement of this speciality at any early stage will affect the quality of mental health act assessments and the safety of patients
Report sections
Investigation and inquest
On 13/10/2016 commenced an investigation into the death of Leah Abby Ratheram: The investigation concluded at the end ofan inquest on 13th March 2017. The conclusion of the inquest was Suicide
Circumstances of the death
The deceased was known to suffer from autism (Asperger's syndrome) and foetal alcohol syndrome and resided in supportive living accommodation. She was vulnerable and had previous episodes of self-harm and had been the subject of an assault in February 2016 and had previously been treated by Birmingham and Solihull Mental Health Trust. She presented at A&E at University Hospital Birmingham on 13/09/16 having taken and overdose of 48 paracetamol tablets She was referred to the RAID team where she was assessed by a nurse at 16.40 and subsequently by a doctor who discharged her with lorazepam and further care from Forward Thinking Birmingham (FTB) home treatment team: FTB took over responsibility for the deceased'$ care on 30/09/16. There was no formal handover to this new organization. On 02/10/16 the deceased a ligature around her neck which was removed by staff where she was living: On 03/10/16 staff contacted the community mental health team at Warstock Lane but were advised care had been transferred to FTB. 04/10/16 she attempted to hang herself at the home where she was living: Initial attempts to contact FTB were unsuccessful. At 19.30 staff spoke to FTB who advised for the deceased to be taken to A&E at University Hospital Birmingham. She was assessed by
Action should be taken
In my opinion action should be taken to prevent future deaths and believe vou have the power t0 take such action.
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Report details
- Reference
- 2017-0081
- Date of report
- 15 March 2017
- Coroner
- Louise Hunt
- Coroner area
- Birmingham and Solihull
Responses identified
Responses identified
0 of 5
5 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 May 2017 (estimated from the report date).
Sent to
- Birmingham and Solihull Mental Health Trust
- Birmingham Children’s Hospital NHS Trust
- Birmingham City Council
- Cross City Clinical Commissioning Group
- NHS England