Source · Prevention of Future Deaths

Julia Hayward

Ref: 2015-0321 Date: 11 Aug 2015 Coroner: Simon Wickens Area: Surrey Responses identified: 1 / 1 View PDF

Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.

Date 11 Aug 2015

56-day deadline 6 Oct 2015 est.

Responses identified 1 of 1

Mental Health related deaths

Coroner's concerns

AI summary

Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.

View full coroner's concerns

During the course of the inquest the evidence revealed that when a decision was made to discharge a patient home and into the care of a family member, following a mental health assessment. The Care Plan was agreed orally and not documented for the family member. Consequently, issues arose as to what was expected/anticipated of the family member under the Care Plan and what was understood by that family member as being their obligations.

The MATTER OF CONCERN is:

Agreement of a Care Plan Consideration should be given to ensuring that following a MHA 1983 assessment where a discharge is decided upon and care plan is agreed (in particular if it places any obligations upon a relative/family member) such plan is clearly documented and a copy of the plan is given to that person/persons as well as the patient discharged.

Responses

1 respondent

Department of Health Central Government

PDF

Noted

The response explains existing protocols and guidance related to the Mental Health Act and assessment/discharge procedures, but does not describe any specific action taken or planned in response to the concerns. (AI summary)

View full response

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Report sections

Investigation and inquest

The inquest into the death of Mrs Julia Ann Clarke Hayward was opened on the 29th May 2014 and was resumed on the 10th August 2015. It was concluded on 11th August 2015. The cause of death was: 1a – Multiple Injuries.

The Narrative conclusion was; On the 23rd May 2014 at the railway lines at St Johns, Woking Julia Ann Hayward died of multiple injuries sustained after she intentionally placed herself in the path of an oncoming train whilst suffering from mental illness. Her intention at the time was unclear.

Circumstances of the death

On the 21st May 2015 Mrs Hayward ran out in front of a lorry. She was not injured but was detained and assessed under the Mental Health Act 1983. Following the assessment and discussion with her husband, Mrs Hayward was discharged home. On the 22nd May 2014 Mrs Hayward was visited at home by the Home Treatment Team. On the 23rd May 2014 after her husband left the home address, Mrs Hayward travelled to the railway line where she accessed the tracks and placed herself in front of a train, which led to her death.

Copies sent to

I have sent a copy of this report to the following1. The Rt Hon Jeremy Hunt MP, Secretary of State for the Department of Health3. The Chief Coroner

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Report details

Reference: 2015-0321
Date of report: 11 August 2015
Coroner: Simon Wickens
Coroner area: Surrey

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: 6 Oct 2015 (estimated).

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.