Source · Prevention of Future Deaths

George Palmer

Ref: 2014-0407 Date: 15 Sep 2014 Coroner: Martin Fleming Area: Surrey Responses identified: 1 / 1 View PDF

Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact were inappropriate.

Date 15 Sep 2014

56-day deadline 10 Nov 2014 est.

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact were inappropriate.

View full coroner's concerns

During the inquest _ Registered Mental Health Nurse; provided helpful evidence and the following concerns were highlighted:- Discharge follow up mechanisms to contact patients who transfer to a different area t0 ensure that are offered continuity of support Appropriateness of follow up letters to the patient in the event of non-contact I would ask that you consider giving further consideration to the above to ensure that there is no further 'repetition

Responses

1 respondent

Surrey and Borders Partnership NHS Trust NHS / Health Body

11 Sep 2014 PDF

Action Taken

The Trust reviewed and reinforced procedures for sharing information with new service providers when patients relocate, including requesting GP details and sending discharge notifications. They have also logged the issues in their corporate action plan and will share learning through quarterly events. (AI summary)

View full response

Dear Mr Fleming Inquest into the death of George Palmer REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Further to the conclusion of the inquest into Mr Palmer's death on 11 September 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with the Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern: We would like to take this opportunity to offer our sincere condolences to Mr Palmer's family for their loss. The areas of concern you raised that relate to our Trust and our responses are detailed below: Discharge follow up mechanisms to contact patients who transfer to a different area to ensure that are offered continuity of support: Our mechanisms to contact Mr Palmer and share information with his GP when he moved to a new area for university did not work as well as we would have expected, for this we are very sorry_ Further to the Inquest; we have reviewed the processes relating to how this Home Treatment Team shares information with new service providers in particular when people who are still in need of mental health services are discharged our services due to their relocation to other parts of the country. Staff in Home Treatment Team have been reminded of the local discharge and follow-up procedures for people discharged from Home Treatment Team. As per our local protocol, our staff will ensure that when are made aware of the eminent relocation of a person who still requires use of mental health services, will request from the person, information relating to their new location of residence including GP details. This is to enable us to refer to another provider of Mental Health Services local to them: If the person is to be registered with a new GP , we will refer to local services in that new location and also inform their original GP of the discharge and any further referrals for completeness: If a person is temporarily registered with a GP in this area, then their original GP is also notified: For abetter life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 ZAD T_0300 55 55 222 F_01372 217111 wwwsabp nhs.uk Surrey they from the they they yet

We will share the full discharge summary with the GP within 7 of the discharge. We also share a short and precise Discharge Notification with the GP which is sent the same day via fax and documented in the progress notes as such and uploaded to Clinical Documentation in our Electronic Patient Record system: This document gives and pertinent facts. For example date of admission and discharge to Home Treatment Team (HTT), current medication, and follow-up. Appropriateness of follow up letters to the patient in the event of non-contact We accept that follow-up letters alone are not sufficient as a means of contact or a way to ensure that people are receiving mental health support in new areas of residence. It is at times challenging for us to ensure that a person who has relocated to a new area is receiving the right level of Mental Health support if they have not registered with GP as the majority of teams are GP aligned. We however work to ensure that people are well supported; for example if patient using our service chooses to visit familylfriends in another area for a period of time, then we proactively ask if they would like mental health input whilst visiting another and a referral is made, supplying information such as current medication prescribed, risk assessment and Care plans_ We have logged the issues outlined in the Regulation 28 report to our corporate action plan and learning from this will be shared with the rest of the organisation through our quarterly serious incident learning events We would like to offer our sincere condolences to the Palmer family for their loss We hope that the steps we have taken as outlined above assure you and Mr Palmer's family that we have learnt and continue to learn from Mr Palmer's death. Please do not hesitate to contact me or Billy Hatifani, Director of Risk & Safety/Deputy Director of Nursing/Emergency Planning Lead if you require any further information:

Report sections

Investigation and inquest

On 11/4/14 I opened the inquest into the death of George Nigel Palmer, who at the date his death was 20 years old The inquest was resumed and concluded on 11/9/14 [found that the cause of death to be: la Hanging I concluded with a narrative conclusion as follows: George Nigel Palmer died by his own hand whilst suffering from anxiety and depression CIRCUMSTANCES OF THE DEATH On 7/4/14 George Nigel Palmer was found to have died at his home address He ws suspended from a belt attached to his bedroom door: He had a previous history of depression and anxiety and because of concerns of self harm, he was admitted to the Priory Hospital as an inpatient between 161-291/1/14, where he was diagnosed as suffering with a major depressive illness, for which he was prescribed medication Upon his discharge he was referred to the Crisis Team and CMHRS and was seen at his home address on 11/2/14 when his mental state was thought to have improved, and upon 20/2/14 when he was assessed as looking forward to starting at Durham University_Because of his RT4283

perceived improvement in his mental health, and his movement to Durham; he was discharged from the CMHRS Although George agreed to provide the contact details of his GP in Durham he did not forward them_in order to facilitate possible further mental health support CORONER'S CONCERNS During the inquest _ Registered Mental Health Nurse; provided helpful evidence and the following concerns were highlighted:- Discharge follow up mechanisms to contact patients who transfer to a different area t0 ensure that are offered continuity of support Appropriateness of follow up letters to the patient in the event of non-contact I would ask that you consider giving further consideration to the above to ensure that there is no further 'repetition ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and [ believe that the CMHRS has the power to take action YOUR RESPONSE You are under a duty to respond to this report within 56 of its date; may extend that on request Your response must contain details of action taken Or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed: COPIES GP Consultant Psychiatrist Chief Coroner Signed: Martin Fleming Assistant Coroner for Surrey DATED this 15t September 2015 RT4283 they days period

Circumstances of the death

On 7/4/14 George Nigel Palmer was found to have died at his home address He ws suspended from a belt attached to his bedroom door: He had a previous history of depression and anxiety and because of concerns of self harm, he was admitted to the Priory Hospital as an inpatient between 161-291/1/14, where he was diagnosed as suffering with a major depressive illness, for which he was prescribed medication Upon his discharge he was referred to the Crisis Team and CMHRS and was seen at his home address on 11/2/14 when his mental state was thought to have improved, and upon 20/2/14 when he was assessed as looking forward to starting at Durham University_Because of his RT4283

perceived improvement in his mental health, and his movement to Durham; he was discharged from the CMHRS Although George agreed to provide the contact details of his GP in Durham he did not forward them_in order to facilitate possible further mental health support

Action should be taken

In my opinion action should be taken to prevent future deaths and [ believe that the CMHRS has the power to take action

Inquest conclusion

George Nigel Palmer died by his own hand whilst suffering from anxiety and depression CIRCUMSTANCES OF THE DEATH On 7/4/14 George Nigel Palmer was found to have died at his home address He ws suspended from a belt attached to his bedroom door: He had a previous history of depression and anxiety and because of concerns of self harm, he was admitted to the Priory Hospital as an inpatient between 161-291/1/14, where he was diagnosed as suffering with a major depressive illness, for which he was prescribed medication Upon his discharge he was referred to the Crisis Team and CMHRS and was seen at his home address on 11/2/14 when his mental state was thought to have improved, and upon 20/2/14 when he was assessed as looking forward to starting at Durham University_Because of his RT4283

perceived improvement in his mental health, and his movement to Durham; he was discharged from the CMHRS Although George agreed to provide the contact details of his GP in Durham he did not forward them_in order to facilitate possible further mental health support CORONER'S CONCERNS During the inquest _ Registered Mental Health Nurse; provided helpful evidence and the following concerns were highlighted:- Discharge follow up mechanisms to contact patients who transfer to a different area t0 ensure that are offered continuity of support Appropriateness of follow up letters to the patient in the event of non-contact I would ask that you consider giving further consideration to the above to ensure that there is no further 'repetition ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and [ believe that the CMHRS has the power to take action YOUR RESPONSE You are under a duty to respond to this report within 56 of its date; may extend that on request Your response must contain details of action taken Or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed: COPIES GP Consultant Psychiatrist Chief Coroner Signed: Martin Fleming Assistant Coroner for Surrey DATED this 15t September 2015 RT4283 they days period

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2014-0407
Date of report: 15 September 2014
Coroner: Martin Fleming
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: 10 Nov 2014 (estimated).

Sent to

Community Mental Health Recovery Services

Source links

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Data: judiciary.uk under OGL.