Source · Prevention of Future Deaths

Graeme Kidd

Ref: 2014-0337 Date: 23 Jul 2014 Coroner: Jacqueline Lake Area: Norfolk Responses identified: 0 / 1 View PDF

Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.

Date 23 Jul 2014
56-day deadline 22 Sep 2014
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.
View full coroner's concerns
In the_ The the taking circumstances it is my statutory duty to report to you. _ (1) Locum Doclors do not have access to electronic CareNotes and other electronic records and systems relating to Patients (2) Locum Doctors are not aware of the various local mental health support Teams available and the criteria which should be used when considering referral to an appropriate part of the service (3) GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service wilhout first undertaking a physical heallh check, thereby causing in cases requiring urgent referral (4) In the absence of the prescribing Doctor, no-one was available to advise the patient as to how the medication was to be taken.

(5) Although an Action Plan has been in place with regard t0 the matters of concern (1) to (4) above, the Plan Is not to be implemented until 30 September 2014_

Report sections

Investigation and inquest
On 7 March 2014 commenced an investigation into the death of Graeme Alexander Kidd , age 42 years: The investigation concluded at the end of the inquest on 16 July 2014 medical cause of death was 1a) cardiogenic shock and hypoxic brain injury, 1b) Asphyxialion from hanging by neck. The conclusion of the inquest was "Suicide whilst the balance of his mind was disturbed and whilst under the care of the mental health services"
Circumstances of the death
Mr Kidd lived with his wife and children: He had a history of mental illness in 2003, which resurfaced in 2008/2009 and in 2010. There had been previous attempts at self harm and to take his own life. Mr Kidd became anxious and down in 2013 and went to his GP_ who restarted medication and referred Mr Kidd as an urgent case to mental health services. Mr Kidd was referred to the Crisis & Home Treatment Team: He was discharged on 6 January 2014. Mr Kidd returned to his GP on 2 occasions and was re-referred to mental health services. He was seen by Consultant Psychiatrist on 21 February and it was decided to wait to see how a previous increase in medication worked. Mr Kidd telephoned the Psychiatrist on Friday 28 February 2014 with low mood and it was agreed he would see how he fared over the weekend. Mr Kidd telephoned Monday 3 March 2014 when it was agreed his medication would be further increased:. Mr Kidd collected the prescription on 5 March. He telephoned Mental Health Services later that day as he was unclear as to how to take the medication: He was to be telephoned back later that day An attempt was made to telephone Mr Kidd on 6 March 2014 On 6 March 2014 Mrs Kidd returned home after the children to school and found her husband hanging: He was taken to hospital and died on 7 March 2014_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has (he power t0 take such action.

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2014-0337
Date of report
23 July 2014
Coroner
Jacqueline Lake
Coroner area
Norfolk

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Sep 2014.

Sent to

Norfolk and Suffolk NHS Foundation Trust

Source links