"GDPR Says Yes"

Benjamin died in prison due to toxicity from prescribed medication. “In evidence there were discrepancies between the policies in place and the understanding of healthcare staff as to what information could be shared with prison staff and when it should be shared. “Some healthcare staff in evidence indicated they would not share information about medication in any circumstances. “The healthcare policy and practice of healthcare staff in relation to information sharing does not align with PSI64/2011 that information can be shared without a prisoner’s consent if it is considered necessary to protect the individual or anyone else from the risk of death or serious harm.”

Miles was arrested while driving under the influence of drink and drugs. He had longstanding mental health needs and was experiencing a psychotic episode. The Police appear not to have realised this and didn't carry out any meaningful assessment of his mental health. They didn't pay adequate attention to information provided by his parents, Adult Social Care and the Mental Health Line. Miles was released from custody, and subsequently crashed his car into an HGV while still suffering a psychotic episode.

Ambulance service and Emergency Operations Centre only have access to GP records, not CMHT records. Evidence was presented that there were technical obstacles to this in respect of interoperability of systems (EMIS/RiO). Evidence also suggested that a person's consent may be needed for this information to be shared across NHS systems including the ambulance service - a clear case of "GDPR Says No".

Trevor died in prison. His cause of death was Sudden Unexpected Death in Epilepsy (SUDEP). His epilepsy was known to prison healthcare staff but not to prison staff. There was no seizure care plan, no seizure diary, and no means of monitoring his condition. Response from prison healthcare provider: “As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.”

Rachel was known to the Intensive Home-Based Treatment Team (IHBTT) to be at high risk of suicide, but they failed to take all the necessary steps to protect her. Her family contacted IHBTT multiple times to raise concerns about her wellbeing, but these were not acted on, and nor were family members given any support and advice about how to care for Rachel.

a.[REDACTED] evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and [REDACTED] of which treating clinicians were aware. On at least one of those occasions [REDACTED] spoke with Spenser Ward staff. I noted that Ms. Woodman had not [REDACTED] given consent for staff to contact [REDACTED] concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from [REDACTED]; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with [REDACTED] on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with . The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community. Although not causative of the death and I noted [REDACTED} ’ very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.