"GDPR Says Yes"

Nisren died after falling over while she was an inpatient in hospital. She had been under the care of the neurology service at a different hospital, but their records were (a) extremely limited and (b) only available via Patient Pass rather than as part of her main hospital record. This meant that clinicians at the hospital where she was an inpatient were unaware of her neurological needs, so weren't observing her as they should have been when she fell.

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.

DWP failed to record information about Naz's mental health needs and vulnerability, despite provision in their IT system for this. Specifically they failed to record Naz's request that contact should be made through her daughter. This contributed to Naz's suicide.

Jacob was stabbed in the neck while out for the night. His attacker had been recently released from prison, but with no co-ordinated plans to manage his serious mental health condition and the risk he posed to others. Along with the lack of integrated working across services, the Coroner identified a specific problem with the healthcare system used in prisons, which had no access to other relevant healthcare records and which didn't display key information in an accessible format.

Serious communication failures between the ambulance dispatcher, the ambulance service and the police over the delay in getting an ambulance to Michael's address. Failure to update Michael's Fast Action Response Plan to reflect the actual level of risk. Shortcomings in software and communication systems amongst agencies. Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned.

Serious communication failures between the ambulance dispatcher, the ambulance service and the police over the delay in getting an ambulance to Michael's address. Failure to update Michael's Fast Action Response Plan to reflect the actual level of risk. Shortcomings in software and communication systems amongst agencies. Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned.

Multiple failures to ensure Gemima was properly assessed by MH professionals, coupled with a system-wide lack of access to relevant information, so that decisions were not informed by knowledge of her full situation

Seven calls were made to the North East Ambulance Service (following the initial call) indicating that Shiya Collins’ condition was deteriorating. Call handlers recognised the need for clinical input in order to facilitate a possible upgrade of the ambulance response to category 1. However, the locking facility on the Cleric computer system used in the control room precluded any clinician from assessing/upgrading the call because the system was locked and unable to be accessed whilst live calls relating to the case were ongoing.

System used to record welfare checks (Excel) was unfit for purpose, as were staff processes for completing and recording these checks.

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.

(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.

Sam's mother had taken her own life when he was 15. He was deeply affected by her death and committed suicide in prison shortly after the 7th anniversary of his mum's death. Although prison staff were aware of how his mum's death had affected Sam, there was no record of a trigger date in either NOMIS (the prison service system) or SystmOne (the prison healthcare system).

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.

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.

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.

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.