"GDPR Says Yes"

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.

Linda had learning difficulties and a mental health condition. She was under the care of the MH team, but they failed to notice her LD and made no reasonable adjustments. Linda overdosed on her medication, and died as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease

(1) Academic Advisor – Better use should be made of the person in this post for each school. There was a wasted opportunity for the academic advisor to be involved in face to face meetings with Daniel and help him when he was struggling to get his work in on time and to deal with his academic pressures. In the circumstances I heard that if work was late a penalty would be imposed. This seems ridiculous; why hit a man when he is already down? (2) With regard to communication – this appeared to be deeply flawed amongst the huge number of University departments and units. The health clinic incorporating amongst other things a pharmacy and the counselling service, was excellent offering free access to students. The system failed – Daniel was not in the link between his GP/counsellor and the student support unit. If this link had been complete I do not believe Daniel would have died when he did.

(1) Academic Advisor – Better use should be made of the person in this post for each school. There was a wasted opportunity for the academic advisor to be involved in face to face meetings with Daniel and help him when he was struggling to get his work in on time and to deal with his academic pressures. In the circumstances I heard that if work was late a penalty would be imposed. This seems ridiculous; why hit a man when he is already down? (2) With regard to communication – this appeared to be deeply flawed amongst the huge number of University departments and units. The health clinic incorporating amongst other things a pharmacy and the counselling service, was excellent offering free access to students. The system failed – Daniel was not in the link between his GP/counsellor and the student support unit. If this link had been complete I do not believe Daniel would have died when he did.

Susan was a resident in a care home who develo-ped pressure ulcers. She was under the care of District Nurses, who asked a GP and the tissue viability team for input, but they were shown out-of-date photographs and didn't appreciate the extent of her deterioration. As a result Susan wasn't precribed antibiotics when she should have been. She deteriorated rapidly and was admitted to hospital, where she died two months later. The DNs also failed to share information with the care team or Susan's family.

Multiple failures including: - Arranging a telephone appointment for someone known to be hard of hearing - Not following up when he didn't answer the phone for the appointment - No communication between the teams treating him

"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."

John was under investigation by the police in respect of allegations made by his ex-partner. He had previously reported to the police that he was the victim of domestic abuse by that same ex-partner. The police failed to follow up on evidence he provided in response to his ex-partner's allegations. They also failed to tell him they would not be taking action against him, leaving him in extreme anxiety and distress and leading to his suicide.

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.

Ryan was a 20yo man with learning disabilities who was also diagnosed with depression. He was arrested and collapsed in the police van, complaining of chest pains. The police took him to hospital where signs of recent self-harm were found. However, the hospital did not investigate his mental state, despite NICE Guidelines which give clear instruction on doing so, and Ryan was released into police custody. (The NICE Guidelines referenced in the PFD report appear to have been superseded in 2022.) The Liaison and Diversion Service attended the custody suite, but failed to record his mental state, nor was he given a mental health assessment. Ryan expressed a desire to self-harm, but custody officers dismissed this as "attention-seeking". They released him to his father, but gave the father no information about what they had seen of Ryan's mental state.

Ryan was a 20yo man with learning disabilities who was also diagnosed with depression. He was arrested and collapsed in the police van, complaining of chest pains. The police took him to hospital where signs of recent self-harm were found. However, the hospital did not investigate his mental state, despite NICE Guidelines which give clear instruction on doing so, and Ryan was released into police custody. (The NICE Guidelines referenced in the PFD report appear to have been superseded in 2022.) The Liaison and Diversion Service attended the custody suite, but failed to record his mental state, nor was he given a mental health assessment. Ryan expressed a desire to self-harm, but custody officers dismissed this as "attention-seeking". They released him to his father, but gave the father no information about what they had seen of Ryan's mental state.

Fern committed suicide after being told that her baby was going to be placed for adoption. This followed a catalogue of failings by Children's Social Care, rooted in their failure to recognise Fern's clinically diagnosed autism, to make any reasonable adjustments for it, or to provide her with an independent advocate while they carried out the s.17 investigation on her baby. The PFD report itself is addressed to the ambulance service and refers to the delay in getting her to hospital after taking an overdose. However, as with Jessie Eastland-Seares, there's a great deal of further detail in the report from georgejulian.co.uk, which paints a clear picture of the communication failures which led her to overdose.

Morgan-Rose took her life while sectioned under the MHA. She was 18 with a diagnosis of Autism Spectrum Disorder; her transition from Children's to Adult1 Social Care had been badly managed, with a lack of information transfer between the two serevices and with no consideration of her own anxieties. MHU staff consistently failed to engage with Morgan-Rose, to the point where she felt they didn't have time for her. They failed to monitor her as they were required to, falsifying observation records and relying on the Oxevision automated observation system instead of face-to-face observations. When Oxevision triggered an alarm to say she had been unattended in the bathroom for three minutes, which should have resulted in an immediate welfare check, the system was reset by an unknown person and Morgan-Rose was left in the bathroom for 50 minutes. Staff had also failed to pick up on warning signals in her behaviour which should have led to heightened alertness. Basic record-keeping was extremely poor, as was the oversight and monitoring of records by senior staff.

Rhys was discharged from hospital following spinal surgery. He and his family were not given clear information about post-surgical risks of VTE or how to mitigate them. He was offered medication, but in the absence of any advice about why it was needed, he declined it. The decision-making process around his discharge was found to be deeply flawed.

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.

(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug [REDACTED], should they drink alcohol or misuse drugs. (2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other’s records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge. (3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends, which may have provided an essential safety net in the absence of accessible professional support.

(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug [REDACTED], should they drink alcohol or misuse drugs. (2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other’s records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge. (3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends, which may have provided an essential safety net in the absence of accessible professional support.

(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug [REDACTED], should they drink alcohol or misuse drugs. (2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other’s records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge. (3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends, which may have provided an essential safety net in the absence of accessible professional support.

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.

Keith was diagnosed through MRI as suffering from degeneration of his lumbar spine which caused impingement of his lower sciatic nerve resulting in chronic pain. He called his GP on three successive days as his pain was increasing. The response from the surgery was chaotic and at times the behaviour of those taking telephone calls was unprofessional and inappropriate. The surgery failed to call him back as promised. On the evening of the third day his family called an ambulance, but Keith suffered a heart attack and died despite CPR.

Nursery failed to listen to Oliver's parents about how far he had progressed with weaning, and failed to tell his parents what they were feeding him. Oliver choked.

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.