Source · Prevention of Future Deaths

David Read

Ref: 2017-0031 Date: 8 Feb 2017 Coroner: Jacqueline Lake Area: Norfolk Responses identified: 1 / 1 View PDF

After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled after a delay of over 16 weeks, during which time the patient died.

Date 8 Feb 2017

56-day deadline 23 Apr 2017 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled after a delay of over 16 weeks, during which time the patient died.

View full coroner's concerns

(1) Mr Read was referred to the Crisis and Resolution Home Treatment Team by his GP on 24 February 2016 as an urgent referral and was seen that evening when it was decided there should be input from the Community Mental Health Team.

(2) On 25 February 2016 Mr Read was referred by a Social Worker at Herring House, where he was residing, to the Community Mental Health Team and he was given an appointment for 21 March 2016, under 4 weeks from the date of the initial referral (3) This appointment was cancelled by Mr Read (no reason is recorded for the cancellation but Mr Read did start alcohol detoxification on this date) and his name was added to the waiting list for a fresh appointment to be arranged: (4) The appointment was treated as a new referral and a new appointment date was sent out on the 18 May 2018 with a new appointment date of 14 July 2016. This is in excess of 16 weeks after the re-referral; Sadly Mr Read died in the meantime. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 10 April 2017 |, the coroner; may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. duly

Responses

1 respondent

Norfolk and Suffolk NHS Trust NHS / Health Body

5 Apr 2017 PDF

Action Taken

Norfolk and Suffolk NHS Trust has fully staffed its team and made amendments to practice. If a service user does not attend an appointment the team will have a phone call to rearrange an appointment instead of sending a letter. The clinical team leader monitors cases that have an appointment pending on a daily basis. (AI summary)

View full response

Dear Ms Lake Regulation 28 report following the inquest of Mr David Read on 23 January 2017 write in response to your report dated 8 February 2017 Under paragraph 7 , Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into death of Mr Read on 23 January 2017 . You recorded the details of Mr Read's contact with the Trust in the period prior to his death, identifying that after cancelling the first appointment with the community mental health team, due for 21 March 2016, the new appointment was arranged for 14 July 2016. Mr Read died in between this time_ Reflecting on this period of time, it is observed there were a number f challenges within the team with respect to vacancies and staff on maternity leave. These had an impact on the team's ability to offer appointments. Subsequent to this period, recruitment to vacancies means the team is currently fully staffed. The team have also made amendments to practice since this time and proposed additional actions upon reflection of your report; with the intention to develop patient safety and experience. These are detailed below. If a service user does not attend an appointment will have a phone call to rearrange an appointment instead of sending a letter The service user will no longer a letter stating that have been on a waiting list. The service user will be given the phone number for the worker so if experience change in their circumstance before attending their appointment they can speak to someone. phone calls to the team or duty worker raising concerns are documented on Lorenzo (the electronic patient record system) and communicated within the team_ Chair: Chief Executive: Michael Scott MINDFUL Trust Headquarters: Hellesdon Hospital, Stonewall EMPLOYER Drayton High Road, Norwich; NR6 SBE DMVERSITY CHAMPION Tel: 01603 421421 Fax: 01603 421440 WWWnsft nhs uk the they get they put duty they Any abour Gary Page stive 1 215ABL*9

Ms Lake The clinical team leader monitors cases that have an appointment pending on a daily basis , taking account of any phone calls or concerns and allocates them a sooner appointment based on the assessment of potential change in risk Thank you for raising this matter of concern, which has assisted the Trust to consider further learning that can be made_ If | can be of any further assistance please do not hesitate to contact me_

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0031
Date of report: 8 February 2017
Coroner: Jacqueline Lake
Coroner area: Norfolk

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 Apr 2017 (estimated).

Sent to

Norfolk and Suffolk NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.