"GDPR Says Yes"

Regina was bed-bound following a hip operation, and was receiving double-handed domiciliary care 4 times per day. Her daughter was dissatisfied with the quality of care provided and asked for it to stop. There was no assessment of Regina's ongoing needs or her mental capacity, nor of her daughter's ability to understand and meet them.

Zara was attacked and killed while walking home alone late at night. Her attacker was under the supervision of the Probation Service and had been recalled to prison when he attacked Zara. A great many concerns were raised, including: - Poor practice, record-keeping, decision-making and communication in the Probation Service, coupled with an "unwieldy" risk management system. - The Police rejecting the findings and recommendations of the Fast Time Review carried out by their own Directorate of Professional Standards. - Shortcomings in CCTV training at the local authority; the Coroner noted that this was partly a lack of two-way communication about the clarity and thoroughness of the training provided. - An equal lack of clarity among the wider public of the need to report sexualised or predatory behaviour.

Christopher was admitted to a private mental health facility commissioned by the NHS. The handover notes at admission were incomplete; the MH facility didn't seek further information from the NHS or from Christopher's famjily, and indeed didn't access his care notes until after his death. Coroner noted that electronic access to NHS records for NHS-commissioned private providers is not provided as standard.

Jake Baker had twin diagnoses of learning disability and type 1 diabetes. He was not capable of, and had not been trained to, manage diabetes independently if he developed hyperglycemia and became unwell. His family had not been given any training to recognise a deterioration in Jake’s condition and when to seek emergency medical assistance. The Coroner identified failures by Surrey County Council including: a.) Failing to obtain information about the risks posed by type 1 diabetes from specialist diabetic services. b.) Failing to obtain information about Jake’s cognitive ability and how it impacted on his ability to manage his diabetes independently. c.) Failing to undertake a risk assessment in relation to his ability to manage diabetes independently. d.) Failing to create an adequate pathway plan which included a proper evaluation of what support Jake needed to have contact with his family e.) Failing to co-ordinate the agencies providing support for Jake to inform the pathway plan. f.) Failing properly to plan for Jake’s care leaving by failing to hold properly minuted and informed meetings prior to making a decision that Jake could have unsupported contact with his family. g.) Failing to ensure that Ruskin Mill Trust were aware that the local authority had not risk assessed Jake having unsupported contact with his family. h.) Failing to inform Jake of the risks of going home unsupported and to suggest ways to mitigate the risks i.) Failing to correctly identify that, had Jake been made aware of the risks and despite that insisted on going home unsupported without any mitigation in place, a capacity assessment would be required. Had such a capacity assessment been undertaken he would have lacked capacity to make that decision and safeguarding measures would have had to be taken. There was also a failure to talk to Jake's family about risks and mitigations or to gather information from them that should have informed their planning and risk assessment.

Jake Baker had twin diagnoses of learning disability and type 1 diabetes. He was not capable of, and had not been trained to, manage diabetes independently if he developed hyperglycemia and became unwell. His family had not been given any training to recognise a deterioration in Jake’s condition and when to seek emergency medical assistance. The Coroner identified failures by Surrey County Council including: a.) Failing to obtain information about the risks posed by type 1 diabetes from specialist diabetic services. b.) Failing to obtain information about Jake’s cognitive ability and how it impacted on his ability to manage his diabetes independently. c.) Failing to undertake a risk assessment in relation to his ability to manage diabetes independently. d.) Failing to create an adequate pathway plan which included a proper evaluation of what support Jake needed to have contact with his family e.) Failing to co-ordinate the agencies providing support for Jake to inform the pathway plan. f.) Failing properly to plan for Jake’s care leaving by failing to hold properly minuted and informed meetings prior to making a decision that Jake could have unsupported contact with his family. g.) Failing to ensure that Ruskin Mill Trust were aware that the local authority had not risk assessed Jake having unsupported contact with his family. h.) Failing to inform Jake of the risks of going home unsupported and to suggest ways to mitigate the risks i.) Failing to correctly identify that, had Jake been made aware of the risks and despite that insisted on going home unsupported without any mitigation in place, a capacity assessment would be required. Had such a capacity assessment been undertaken he would have lacked capacity to make that decision and safeguarding measures would have had to be taken. There was also a failure to talk to Jake's family about risks and mitigations or to gather information from them that should have informed their planning and risk assessment.

"There was a lack of information sharing and investigation in relation to the discharge planning for Mr Clayton. Contrary to the Trust’s policy he was not identified as a vulnerable patient. His family was not involved in the discharge planning. On a number of occasions, they raised their concerns as to his ability to live independently and were ignored. Staff were unaware of the discharge planning policy. The underlying cause for his presentation was not diagnosed. Discharge decisions were taken in a vacuum without understanding the recent history of frequent admissions, his diagnosis and without sufficient investigation of his home circumstances."

Trevor was admitted to psychiatric hospital “in an agitated, even psychotic state” and unable to give staff his medical history His sister told staff that he was suffering heart problems, but they did not record this. Trevor died from his heart condition within 48 hours of being admitted to the psychiatric unit.

Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances." A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs. Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.

Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances." A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs. Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.

Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances." A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs. Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.

Karmchand was admitted to hospital with acute intestinal obstruction. He was placed on the wrong referral pathway, resulting in severe delay to the surgery he needed. Observations were not carried out properly while he was awaiting surgery. Karmchand was unable to communicate the pain he was feeling to hospital staff. His family raised concerns, as did hospital staff who knew him, "but adequate notice does not appear to have been taken."

Michaela was in a relationship with a prolific offender who murdered her in her home by stabbing her in the eye. The Coroner found multiple failings across a number of services, including police, probation and adult and children's social care. These included: - An inadequate assessment of the risk posed to Michaela and her children by her partner - Multiple failures to communicate between agencies - A lack of professional curiosity leading to a failure to investigate the perpetrator's mental impairment, despite clear warning signs - Failure to act on or share information received from family members. The PFD report quotes from the Coroner's full judgement, which is not available at judiciary.uk, but which is likely to add clarity about these failings and the steps needed to correct them.

Kim died after being attacked by his son, who was under inadequate care from the MH team. They had not carried out MH assessments for the son in accordance with s.13 MHA, in that (among other things) they had disregarded the information repeatedly provided by Kim and his wife. A proper MH assessment would have led to Kim's son being sectioned and prevented from attacking Kim.

Kim died after being attacked by his son, who was under inadequate care from the MH team. They had not carried out MH assessments for the son in accordance with s.13 MHA, in that (among other things) they had disregarded the information repeatedly provided by Kim and his wife. A proper MH assessment would have led to Kim's son being sectioned and prevented from attacking Kim.

(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment. Despite the evidence that significant changes are being put in place the efficacy of these changes has not yet been evidenced. (2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk. (3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public. (4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger.

Emmanuel had been diagnosed with paranoid schizophrenia and depression, and was under the treatment of the community MH team. They repeatedly failed to engage with his sister, with whom he lived and who wanted to be involved in his care. The Coroner highlighted four previous PFD reports she had sent to the Trust citing the same concern, dating back to 2015.

Sally died after being stabbed by her son, who had a history of schizophrenia. The Coroner found extensive evidence of professional failures by both the health service and adult social care to get effective treatment for her son, despite Sally having raised repeated concerns.

Multiple concerns about the Trust's approach to risk assessment (including a failure to prescribe appropriate medication); the way they carried out observations; and failure to pay regard to information provided by Larry's partner, which was put on the record but ignored.

1) Mr Lockwood’s re-admission to hospital was indicated as early as 2 February 2023; however, he was not re-admitted to hospital, informally or otherwise. 2) A verbal referral was made for Mr Whitelaw to be urgently reviewed by a psychiatrist following the appointment on 2 February 2023, but not acted on. 3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following: – There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment – “Discussions and assessments of risk should be clearly documented” – “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions” – There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”

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.

We, the jury, find the: 1. Failure to remove the bedsheet and close the hatch allowing Jack to create a ligature point 2. Failure to refer to Liaison and Diversion services in Central and North-West London and the failure to open an ACCT whilst in prison custody, either of which would have triggered a more thorough risk assessment 3. The difficulties accessing relevant and important information relevant to J. Zarrop’s history, both medical and custodial were the main contributing factors to the death of J. Zarrop.

We, the jury, find the: 1. Failure to remove the bedsheet and close the hatch allowing Jack to create a ligature point 2. Failure to refer to Liaison and Diversion services in Central and North-West London and the failure to open an ACCT whilst in prison custody, either of which would have triggered a more thorough risk assessment 3. The difficulties accessing relevant and important information relevant to J. Zarrop’s history, both medical and custodial were the main contributing factors to the death of J. Zarrop.