"GDPR Says Yes"

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.

Lauren had been sectioned and placed with The Priory at a distance of approx 260 miles from home. Lack of system integration or clinical communication between the commissioning MH trust and The Priory Failure to record Lauren on a list of out-of-area patients, leading to a failure to find her a place nearer home when she was ready for step-down from PICU.

Lauren had been sectioned and placed with The Priory at a distance of approx 260 miles from home. Lack of system integration or clinical communication between the commissioning MH trust and The Priory Failure to record Lauren on a list of out-of-area patients, leading to a failure to find her a place nearer home when she was ready for step-down from PICU.

a. There was no evidence of any formal investigation having been undertaken into how the referral for ERCP became lost. It appears that only during the course of Inquest proceedings did the issue relating to the lost referral become known to the Health Board. Even once it became known to them in 2022 there was still no investigation undertaken. It is not understood at all which incidents that occur are to be investigated. I have issued a number of Prevention of Future Death Reports relating to investigations and governance and yet these concerns continue. I am not in any way satisfied that improvements have occurred. b. Given that no investigation was conducted to understand how the issue may have occurred there has been no learning, change or improvement to ensure it is not repeated. I have been provided with no assurances in this regard. c. There was no evidence that any audits had taken place to review whether any other patients’ referrals had become ‘lost’. d. Matters relating to the ERCP which did not take place were identified by the Medical Examiners in their report dated 4 days after the deceased’s death. There was no evidence as to whether the Health Board had been made aware of the concerns therein and if so, what action they had undertaken as a result. e. Evidence was heard relating to electronic notes and referrals. Such referrals remain paper based and there is no indication as yet when these will be fully electronic. I am aware that this national strategy is ongoing but the time it is taking is putting patients’ lives at risk.

"Lack of integration between mental health and physical healthcare systems... Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison’s death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as “private” providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths."

"Lack of integration between mental health and physical healthcare systems... Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison’s death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as “private” providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths."

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.

Shahzadi, from Manchester, had been sectioned under the MHA and had been in a private MHU in Norfolk. Her family were unable to visit, leading to Shahzadi feeling isolated and clinicians not being able to have the family's input to her treatment. There were significant communication failures at the time of Shahzadi's discharge, leading to a failure to provide s.117 after-care and placement on the wrong clinical pathway. In the absence of the right care and support, Shahzadi took a fatal overdose.