Vanessa Dadswell

Coroner's concerns

AI summary

Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency care.

View full coroner's concerns

During the course of the inquest the evidence revealed that any urgent referral by a GP would be categorised by West Sussex Community Mental Health as either as a ‘4 hour’ referral or a ‘within 5 day’ referral. A ‘4 hour’ referral would involve the service user having to attend A&E urgently for an assessment within 4 hours. A ‘within 5 day referral’ was exactly as described, an appointment within 5 days. The issue arose where a referring GP did not consider it necessary nor appropriate for a 4 hour referral and yet believed a 24 hour visit was necessary as 5 days would be too long. The deceased was not seen within 24 hours and committed suicide 3 days after the referral with no direct contact having been made. Evidence given by the Service manager for the Trust agreed that an intermediate option for referral would not be unreasonable.

The MATTER OF CONCERN is:

Consideration should be given to an alternative, intermediate referral time between the current ‘4 hour’ and ‘within 5 day’ periods for referrals together with effective management thereof.

Responses

1 respondent

Vanessa DADSWELL

15 Apr 2016 PDF

Action Taken

The triage system has been improved with direct bookable Priority Appointment slots for Triage Team Leaders and senior staff oversight. A protocol encompassing the improved system is being drafted throughout Coastal West Sussex CDS, and learning from the inquest will be presented to the Adult Management Board. (AI summary)

View full response

Dear Sir Re: The inquest touching the death of Vanessa Dadswell Thank you for your letter and report of 17 February 2016, written pursuant Paragraph (1) of Schedule 5 to the Coroners & Justice Act 2009, and for highlighting your concerns. Firstly , may offer my sincere condolences to Mr Dadswell: hope this letter will assure you, and Mr Dadswell, that the matters you have raised have been taken seriously and improvements in Sussex Partnership have been made to enhance the service we provide to service users and their families_ As you heard at the inquest; historically , urgent General Practitioner referrals into West Sussex triage were taken by the triage worker and passed to the Assessment & Treatment team to action: The options available were to be seen within 4 hours or within 5 working days_ The system has since been reviewed and improved to allow greater flexibility_ The system improvements are as follows: Triage Team Leaders now have direct bookable Priority Appointment slots and do need t0 pass priority referrals to the Assessment & Treatment Duty Worker for booking_ There is senior staff oversight of the new system whereby the Triage Team Leader takes ownership and makes contact with the General Practitioner and service user throughout the process_ The Team Leader prioritises the incoming work on a daily basis and supports the triage workers_ Every morning the Triage Team Leader assesses all incoming referrals received out of hours and; if the referrer has requested the service user to be seen within 24 hours but did not consider a 4 hour response was clinically required, appointments within 24 hours are arranged: Referrals can be fast track allocated by the Triage Team Leader so they do not wait up to 5 days for a slot; they are given the first available appointment;, dependent on assessment of risk, often within 2-3 days. If the member of staff taking the referral out of hours has any concerns about the referral or appointment needs, they now immediately escalate the referral to the on call manager. Chair: Caroline Armitage Chief Executive: Colm Donaghy Trust Headquarters: Sussex Partnership NHS Foundation Trust; Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP wwWsussexpartnership nhsuk Teaching Trust of Brighton and Sussex Medical School not

More home visits are now offered where clinically indicated (as in Mrs Dadswells case). All referrals and referral decisions, including the rationale behind the decision, documented on our new electronic records system, CareNotes, which all clinical staff Trust wide have access to In addition, we are recruiting a full time band 7 member of staff to provide cover to the Team Leaders in times of absence to ensure the system is robust and reliant on any one individual Penny Fenton; General Manager Coastal West Sussex Care Delivery Service (CDS) , Nadia Anderson, Service Manager Western, Working Age Mental Health Services, Coastal West Sussex Care Delivery Service (CDS) and Liam Rudden; Service Manager for Adur, Arun & Worthing Assessment and Treatment Service are currently drafting a protocol encompassing the improved system throughout Coastal West Sussex CDS. The checklist and flowchart developed and exhibited at the inquest will be appended so there is a clear user friendly for staff, Dr Brian Solts , Divisional Clinical Director Coastal West Sussex Care Delivery Service (CDS) has confirmed he will present the protocol, together with the learning from Mrs Dadswell's inquest, to the Adult Management Board to maximize learning and embed the improvements introduced. The Service Specification for the Urgent Care Pathway detailing the 4 hour and 5 day referral options was developed in partnership with our West Sussex Commissioners and is due for renewal_ Dr Solts has requested meeting to be arranged with the West Sussex Mental Health commissioners to review the pathway jointly with US, in light of the improvements we have made, and the greater flexibility we have introduced, so it reflects current practice. Furthermore, Dr Solts is hosting a % Report and Learn Forum for Coastal West Sussex CDS which will identify learning from incidents and inquests and he will share the learning (anonymously) from Mrs Dadswell's inquest so CDS staff can reflect and take forward the lessons learned. As a Trust we are committed to learning and improving safety: Lessons from Mrs Dadswell's inquest were shared (anonymously) through the Trust's monthly Report and Learn Bulletin and via the Trust's Quarterly Quality and Safety Report; both are distributed throughout the Trust and externally with our Clinical Commissioning Groups. The Trust has no objections to this letter being shared or published by the Chief Coroner:

Report sections

Investigation and inquest

The inquest into the death of Vanessa Christine Dadswell was opened on the 13th April 2015 and was resumed on the 8th February 2016. The cause of death was found to be: 1a – Multiple injuries.

A short form conclusion of ‘suicide’ was returned.

Circumstances of the death

On the afternoon of the 2nd April 2015, Mrs Vanessa Dadswell attended Whitley Railway Station whereupon she placed herself in the path of an oncoming train and died of injuries sustained. She had been referred by her GP via the urgent referral scheme to the Mental Health Services on the 30th March 2015. Her GP requested a 24 hours referral. The options made available were a 4 hour or within 5 day referral. The GP indicated a 4 hour referral was not necessary but she should be seen ideally with 24 hours. Mrs Dadswell had not been seen by Mental Health Services before her death on the 2nd April 2015. However a direct causal link between the missed opportunity of an assessment and her death could not be RT4730

established upon the evidence.

Copies sent to

I have sent a copy of this report to the followingb RT4730RT4730 c2. The Chief CoronerSignedSimon WickensDATED this 17th February 2016

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