Source · Prevention of Future Deaths

Michaela Thompson

Ref: 2016-0392 Date: 2 Nov 2016 Coroner: David Hinchliff Area: West Yorkshire (East) Responses identified: 1 / 1 View PDF

Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.

Date 2 Nov 2016
56-day deadline 28 Dec 2016 est.
Responses identified 1 of 1
Suicide (from 2015)

Coroner's concerns

AI summary
Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.
View full coroner's concerns
_ (1) Michaela was the subject of multi-disciplinary team meetings which were inadequately documented in the case notes. It should be clearly documented as to who was present and participating in such meetings_ The identification of those involved should be clearly recorded, as should the outcome of and decisions made at such meetings.

(2) On the morning that Michaela Thompson died_she_had telephoned Aire Court in the Sara The The her - being two presence of a friend who noticed that she became anxious and upset during that brief call: There was no record kept as to the nature of the call or any information or advice given, nor was the fact of the call immediately communicated to the Community Mental Health Nurse involved. Calls t0 the Service should therefore be recorded; to ensure that details of the nature of the call; its urgency; and the action taken by a named individual or individuals can be clearly ascertained_

Responses

1 respondent
Leeds and York NHS Trust NHS / Health Body
8 Dec 2016 PDF
Action Planned

The trust acknowledges the need for clear documentation of MDT meetings and recording phone calls. They propose a meeting to discuss the practicalities of recording calls before implementing a solution. (AI summary)

View full response
Dear Mr Hinchliff The letter and your regulation 28 requirements (attached)were forwarded t0 me for consideration: has now left his post and we have an interim medical director): am aware of Miss Thompson's care and sad death therefore fully accept your requirement that there should be clear documentation as to who is present at multi-disciplinary team meetings along with clear documentation of any outcomes and decisions made. it is therefore something which we of course in place. can also fully understand the rationale behind the second requirement as it was reported that Miss Thompson was distressed and anxious at the time of the phone call to Aire Court: It is clearly upsetting to the family who are unable to determine what was discussed in the phone call and who had that discussion with Miss Thompson: have discussed this with the clinical team involved and similarly feel that recording phone calls would be helpful for the future given their experience in this case There are however some practical difficulties in that there are multiple phone lines coming into each team and these are used for a variety of reasons, sometimes by service users but also by other professionals and outside agencies: The practicalities of recording all of these calls could therefore be difficult; However; &s agreed by the team, do think the facility to record calls coming into clinical services is important and agree with what presume to be the rationale behind this requirement: wonder though, given the practical challenges, whether it would be useful to discuss this a little further so that am clear about you intend to be achieved by this so that we are able to do something that is both practically feasible and also meets both your requirements and those for people who use our services in the future. improving teaching organisation providing mental health and learning disability services Alma Nervalve ` will put they likely health , improving lives

Leeds and York Partnership NNHS NHS Foundation Trust would therefore ask if we could arrange a relatively brief meeting to discuss this so that we can implement it; in a way that addresses the concerns that you have identified?

Report sections

Investigation and inquest
On 2nd December 2015 | commenced an investigation into the death of Michaela Louise Thompson; age 36, The investigation concluded at the end of the Inquest on 19th October 2016. conclusion of the Inquest was a Narrative; a copy of which attach: The medical cause of death was:- 1(a) Hanging
Circumstances of the death
deceased was separated from her husband and lived with her two children aged 5 and 10, and had a medical history of suffering with depression. Mrs Thompson believed that she was suffering with a borderline personality disorder andlor bipolar disorder. These conditions had not been formally diagnosed Miss Thompson had a long association with mental health services and was fully compliant with all treatment options. She had not been seen by a psychiatrist nor had any mental health assessment. She had regular suicidal thought culminating in taking her own life by an act of self-suspension at her home address, her death confirmed there at 1724 hours on 1*t December 2015.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.

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Report details

Reference
2016-0392
Date of report
2 November 2016
Coroner
David Hinchliff
Coroner area
West Yorkshire (East)

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: 28 Dec 2016 (estimated).

Sent to

Leeds and York Partnership NHS Foundation Trust

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