Source · Prevention of Future Deaths

Miles Abel

Ref: 2016-wp25345 Date: 29 Jul 2016 Coroner: Ian Singleton Area: Wiltshire and Swindon Responses identified: 2 / 2 View PDF

The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.

Date 29 Jul 2016

56-day deadline 26 Sep 2016

Responses identified 2 of 2

Community health care and emergency services related deaths Suicide (from 2015)

Coroner's concerns

AI summary

The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.

View full coroner's concerns

(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent.

(2) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed.

(3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental health Team would be unaware of the fact a patient had been referred to them. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223

Responses

2 respondents

The Endless Street Doctors Surgery

PDF

Action Taken

The Endless Street Doctors' Surgery has implemented a new Standard Operating Procedure for urgent faxes. This includes a fax log, scanning a dated 'faxed' stamp into patient notes, and requiring the sender to call the recipient to confirm receipt, documenting the conversation, and tasking the referring doctor with confirmation of successful transmission. (AI summary)

Department of Health Central Government

PDF

Noted

The Department of Health acknowledges the local issue with faxed referrals and notes that the Endless Street Surgery has implemented a strengthened system. They highlight broader government initiatives for digitising the NHS, including integrated care, paper-free services, and transforming general practice. (AI summary)

Report sections

Investigation and inquest

On 15/01/2016 I commenced an investigation into the death of Miles Benedict Abel, 48. The investigation concluded at the end of the inquest on 07 July 2016. The conclusion of the inquest was suicide.

Circumstances of the death

On the 14 January 2016 whilst at home at 1 Francis Villas Kingsland Road Salisbury Wiltshire Miles placed a ligature around his neck, attached the other end to a window which caused the injuries which led to his death.

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Shared signals

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Report details

Reference: 2016-wp25345
Date of report: 29 July 2016
Coroner: Ian Singleton
Coroner area: Wiltshire and Swindon

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 Sep 2016.

Sent to

Department of Health and Social Care

Endless Street Surgery

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.