Source · Prevention of Future Deaths
Julia Dell
Ref: 2014-0021
Date: 17 Jan 2014
Coroner: Andrew Cox
Area: Cornwall
Responses identified: 0 / 3
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The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
Date
17 Jan 2014
56-day deadline
14 Mar 2014 est.
Responses identified
0 of 3
Coroner's concerns
The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
View full coroner's concerns
At the inquest I found that the medical service Mrs Dell had received from primary care during the period from July 2011 until 4 April 2012 had been exemplary. This included the period from mid December 2011 until mid April 2012 when responsibility for Mrs Dell’s care passed to Cornwall Partnership NHS Foundation Trust.
I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to and who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, conceded that: “it would have been nice for there to have been more involvement from primary care after April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between to in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health
Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her not withistanding the fact that only three weeks previously on 22 March 2012 had contacted to express his concerns over Mrs Dell’s wellbeing
I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to and who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, conceded that: “it would have been nice for there to have been more involvement from primary care after April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between to in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health
Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her not withistanding the fact that only three weeks previously on 22 March 2012 had contacted to express his concerns over Mrs Dell’s wellbeing
Report sections
Investigation and inquest
On 24 August 2012 I commenced an investigation into the death of JULIA SHIREEN DELL then aged 45. The investigation concluded at the end of the inquest on Monday 13 January. The conclusion of the inquest was that was Mrs Dell took her own life. She died of multiple injuries having been witnessed to jump from cliffs at Duckpool Beach, Kilkhampton, Bude in Cornwall
Circumstances of the death
I found that the cause of Mrs Dell’s death was multifactorial. I found that the initiating and most significant event was the collapse and then liquidation of the family business. Other contributory features included:
(A) An increasing realisation that her children were leaving home; (B) The fact that her parents had recently informed her they intended to move to St
Albans; (C) Pressures relating to her work; (D) A feeling of being controlled by family members; (E) Confusion and/or a lack of compliance in taking the medications prescribed to her (F) Difficulties in her marital relationship; (G) The probability that she was suffering from a form of bi-polar disorder.
(A) An increasing realisation that her children were leaving home; (B) The fact that her parents had recently informed her they intended to move to St
Albans; (C) Pressures relating to her work; (D) A feeling of being controlled by family members; (E) Confusion and/or a lack of compliance in taking the medications prescribed to her (F) Difficulties in her marital relationship; (G) The probability that she was suffering from a form of bi-polar disorder.
Action should be taken
In particular, I would ask you to consider whether it is appropriate to have a formal handover where patients pass from one doctor to another within the surgery. This would seem more relevant where there are urgent or ongoing medical problems.
I would also ask you to consider whether it is appropriate, on all occasions, simply to place reliance upon a discharge letter and care plan without additional enquiry. That seems to be particularly the case where a discharge takes place in circumstances that appear at odds with the knowledge known to the doctors within the surgery.
I would also ask you to consider whether it is appropriate, on all occasions, simply to place reliance upon a discharge letter and care plan without additional enquiry. That seems to be particularly the case where a discharge takes place in circumstances that appear at odds with the knowledge known to the doctors within the surgery.
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Report details
- Reference
- 2014-0021
- Date of report
- 17 January 2014
- Coroner
- Andrew Cox
- Coroner area
- Cornwall
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 Mar 2014 (estimated).
Sent to
- Royal Cornwall Hospital Trust
- Medical Centre
- Stratton, Bude, Cornwall