Leicestershire Partnership NHS Trust
NHS / Health Body
Noted
Leicestershire Partnership NHS Trust has implemented a robust system for seeking clinical information and has a flowchart identifying team member responsibilities. However, following review of the case notes, it was felt that anti-depressant medication was not clinically indicated and therefore an opportunity to restart medication was not missed. (AI summary)
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Dear Mrs Brown; Re. Mr Greg Revell Further to your report dated 28 April 2015, in accordance with paragraph 7 , Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 offer the following response. We have investigated the matters of concern that have arisen during the course of the inquest of Mr Greg Revell Leicestershire Partnership NHS Trust takes these matters very seriously and hope that you and Mr Revell's family will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again: Carole Robson, Service Manager for Prison Healthcare, will be leading on our response. The system for capturing all available healthcare information was insufficiently robust: There was no clear monitoring of obtaining a GP summary promptly to ensure medications and previous medical history could be checked as soon as possible: We now have a robust system in regard how clinical information is sought and there is a flow chart (Attachment 1) identifying team member's responsibilities to ensure consistency and follow up if required. This flowchart details the responsibility of each discipline within the team to ensure that there is a robust mechanism in place t0 ensure that Prisoners Clinical Notes are requested and followed up. flow chart details that staff have a responsibility to escalate their concerns initially to a Clinical Nurse Manager who will then in turn Iiaise with the Healthcare Manager at the specific Prison. Should the matter go unresolved that the Healthcare Manager escalate his her concerns to the next level to the Prison Healthcare Service Manager. In addition the situation will have been reported on our risk reporting system which also ensures that this information is scrutinised at a senior level within the organisation: Chair; Professor David Chiddick CBE Chief Executive; Dr Peter Miller 2 City The willl Mout Ative 015a8149
An opportunity for restarting anti-depressant medication in this case was missed_ the Clinical Director for Prisoners has reviewed the patient's case notes and has also reflected on the investigation findings: Anti-depressant medication was considered but having reviewed the clinical notes it would appear that the prescribing of anti-depressant medication was not clinically indicated. It is felt therefore that on this occasion an opportunity for restarting anti-depressant medication in this case was not missed.
An opportunity for restarting anti-depressant medication in this case was missed_ the Clinical Director for Prisoners has reviewed the patient's case notes and has also reflected on the investigation findings: Anti-depressant medication was considered but having reviewed the clinical notes it would appear that the prescribing of anti-depressant medication was not clinically indicated. It is felt therefore that on this occasion an opportunity for restarting anti-depressant medication in this case was not missed.