"GDPR Says Yes"

The GP made a referral to secondary mental health services, but this was not acted on as Leya was already under the care of the primary MH team. The primary team also failed to act on the referral as they didn't feel it was urgent enough.

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

Prescribed the same medication twice, by GP and hospital; neither had checked what the other had issued to her. The resulting double dose was fatal.

"Matthew’s death was probably the result of systemic failures across multiple agencies including the Prison services.... There was inadequate communication between agencies and a lack of information sharing. This probably led to a failure to identify his deteriorating mental health and increasing suicide risk.

Jacqueline's hospital record may or may not have included a flag about her risk of medication abuse. She was discharged home from hospital with an excess prescription of her medication despite a warning note on her [GP?] record stating that she should only be given 7 days' supply.

“Mr Cassidy died from a known drug allergy because its existence was not obtained by hospital medical staff from his Summary Care Record.”

Staff at Peter's residential home failed to follow his Eating and Drinking plan, as a result of which he choked.

Donna had an atypical eating disorder which was not picked up by the MH team when she was admitted to hospital. As a result she was discharged. When she came back into hospital three days later, the notes from her previous stay weren't available to the clinicians assessing her. She was again discharged home, where she died.

"Raymond was admitted to hospital the day before with a history of recent falls attributable to orthostatic hypotension and was frail by virtue of his age. The falls risk assessment, prior to the fall on the ward, did not accurately take into account this history and as a consequence there was no assessment in respect of his additional care needs which more likely than not should have resulted in 1:1 care which probably would have avoided the severity of the injury by managing the fall when he needed to urinate or avoided him having to get out of bed in the first place."

Discharge and safety netting The discharge report for Gareth did not contain details of his diagnosis or sufficient information about high-risk behaviours/triggers. The information within the discharge report was not fit for purpose and did not provide for an accurate or full handover to new healthcare professionals. Review of the medical notes There was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth. There was no written guidance on this issue and it lead to Gareth being seen by healthcare professionals who did not have an up-to-date understanding of Gareth’s condition and mental state. Failure to update risk assessment There was a failure to update Gareth’s risk assessment, which at the date of his death was last updated on 7 April 2022. Gareth’s presentation had materially changed since 7 April 2022, and so the risk assessment effectively became redundant by virtue of the failure to update it. This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours. In evidence it became apparent that the Trust did not have a system in place for routinely checking and updating the risk assessments. Record Keeping There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth. There is no audit system in place to check the records.

"During the inquest I heard from the carers who worked with Mr Godderidge. They reported to me that when concerns are raised about a service-user’s capacity there is not reliable and routine liaison between Adult Social Care and the care providers. I am concerned that this gives rise to a risk of future deaths. Care workers are very likely to see a service user more often than others. They have a particularly valuable perspective as to a person’s capacity. If their observations are not being considered then opportunities to provide care to vulnerable people may well be missed. Mr Godderidge’s carers also reported to me that in their experience consideration of capacity by Adult Social Care does not always reflect the possibility that a person’s capacity may be variable and fluctuating. I am concerned that this gives rise to a risk of future deaths if a person is considered on a ‘good day’ without understanding that their presentation fluctuates substantially over time."

Failure by ASC to take appropriate action when a safeguarding concern was raised (self-neglect). Failure to act on a referral for a needs assessment. Multiple general failures to communicate between teams within ASC.

(1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment. (2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P. (3) When the G.P re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact. (3) As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual diagnosis.

(1) During the inquest, it became clear that one significant entry in the clinical notes made by someone in a separate service commissioned by the Essex Partnership University Trust, and which expressed a very specific and imminent intention from the deceased to end her life, was not seen by others in the clinical team. This was almost certainly because the clinical record does not present on computer screens as a continuous chronological running record, but is instead viewed thematically. That means that readers are likely to look at entries made within their particular clinical team, rather than see what others have recorded more recently. There is an obvious risk that critical and important information garnered by others and put into the medical records will not be seen, and that those making clinical decisions on risk management will thus be unaware of potentially very significant information. The evidence was such that neither the care co- Ordinator nor the consultant psychiatrist as the medical lead of the service specifically considered the structured risk management tools that the Trust operates, preferring to rely on clinical experience and judgment alone. There may be a risk that not using such risk management tools in combination with clinical experience and judgment, particularly if this is being done by one clinician at an appointment rather than multidisciplinary discussion of changes in presentation, may lead to information being missed. There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care- co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendances at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be, and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations.

Repeated failures by ASC to respond to multiple reports of safeguarding concerns and requests for Carer Act assessments

As previously raised in Report to Prevent Future Deaths dated 23 December 2021, incoming correspondence to the GP practice continues to be dealt with by administrative staff who decide whether or not it is placed before a GP. The concern is that there is no robust system in place to ensure that communication to the surgery which may require action to be taken by medical staff is brought to their attention. Adverse medication markers are not being placed on computerised medical records and this creates the risk that contraindicated medications may be inadvertently prescribed.

(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.

The current SCR model does not appear to automatically flag drugs such as steroids, which are known to have potentially fatal side effects if used for the long term without appropriate monitoring. It is understood that some drugs do have these flags, but that steroids do not. In addition, the SCR does not have a space recording for clinical indication for initiation of the drugs, to aid a future prescriber to consider whether the drug is still clinically indicated.

1. Awareness of and compliance with St. Andrew’s Healthcare ‘Pressure Ulcer Prevention and Management’ Policy Due to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure damage and ought to have had weekly waterlow assessments and daily skin inspections with more frequent assessment and inspection to be considered in the event of change such as the development of an ulcer. Statements were provided from [REDACTED], Consultant Psychiatrist, [REDCATED]and, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The statements included information on Mr. Mishabi’s waterlow assessment and skin inspections, and provided some records. At no time was it identified that the SAH ‘Pressure Ulcer Prevention and Management Policy’ was not followed in Mr. Mishabi’s case. At inquest it was identified that [REDACTED] had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it). The areas of non compliance identified at inquest were as follows: a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and 4.3 of the policy; b. failure to carry out and/or adequately record daily skin inspections in accordance with paragraph 4.4 of the policy; c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph 4.3 of the policy; d. failure to consider increasing the frequency of skin inspections and carry out and/or adequately record any skin inspections between the identification of ulcers on the 15th March 2023 and the admission to hospital on the 17th March 2023 in accordance with paragraph 4.4 of the policy; and e. failure to make a datix incident report when grade II lesions were identified on the 15th March 2023 in accordance with paragraph 4.7 of the policy; and f. failure to provide adequate monitoring and oversight of the implementation of the policy in Mr. Mishabi’s case in accordance with paragraph 5 of the policy. 2. SAH Governance, Quality Assurance and Serious Incident processors a. SAH had not identified the issues with compliance with the policy before the inquest and could offer no explanation for how/why the failures occurred and persisted. b. No serious incident investigation had been carried out by SAH into Mr. Mishabi’s death because it was mistakenly believed that the ulcers developed during the admission to hospital between the 17th March and 2nd April 2023. However, it was acknowledged in a statement from [REDACTED]of the 14th September 2023 that there were records showing ulcers were present from the 15th March 2023. c. [REDACTED] SAH Deputy Medical Director, gave evidence that the failures to comply with the policy ought to have been identified by review of the physical health dashboard in monthly ward governance huddles and the monthly divisional Integrated Quality and Performance meeting (IQPR). As there had been no investigation into what went wrong she could not explain why these systems did not work.

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.

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.

Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children? The following specific issues were identified: The patient safety plans are not always read and understood by transport crew. Home visits between passenger and transport crew often do not occur when contractually required. The local authority are often not notified of personnel changes in the transport crew. The need for proper handovers at drop off and pick up is not understood. There is no requirement for transport crew to be qualified first aiders. The passenger assessment test requires further improvement. There is no comprehensive schedule for inspection of transport operators. There is no mandatory training or forums for operators to attend where information can be cascaded to them. Operators have to approach multiple organisations which leads to confusion and inconsistency.

The Court heard evidence despite a warning ‘flag’ being present on the computerised records identifying the existence of an individualised care plan for Darnell, the care plan was hard to locate in the records, and was not considered during his admission.

Evidence was given that: Although the wrist alarm had been reported as broken and not working on the 6.1.2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home between 11-12.1.2024. At the time the deceased fell, she was wearing her wrist alarm but could not use it to summon help because it did not work. None of the carers who attended on the deceased after 6.1.2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority. The last carer who attended on the deceased before she died, on the 11.1.2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users. None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending upon service users. There was no clear system identified between the company providing carers and the local authority, as to the duties and responsibilities of each in the reporting of faults with wrist alarms.

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.”

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.