Annabel Findlay
PFD Report
All Responded
Ref: 2023-0080Deceased
All 1 response received
· Deadline: 26 Apr 2023
Coroner's Concerns (AI summary)
The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was made, and attempts to contact her post-discharge were significantly delayed.
View full coroner's concerns
Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointment was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findlay until 6 September 2021 (some 10 days following her discharge).
Responses
Action Taken
The Priory Group has circulated reminders to medical colleagues to ensure outpatient follow-up appointments are booked prior to patient discharge. They have also reminded staff to make telephone contact with patients 48 hours after discharge and are auditing this process monthly. (AI summary)
The Priory Group has circulated reminders to medical colleagues to ensure outpatient follow-up appointments are booked prior to patient discharge. They have also reminded staff to make telephone contact with patients 48 hours after discharge and are auditing this process monthly. (AI summary)
View full response
Dear Mr Taylor,
Ms Annabel Jean Findlay - Response to Regulation 28 Report
I write to you in response to the Regulation 28 Report dated Wednesday 1 March 2023. The report was issued following the Inquest touching the death of Ms Annabel Findlay. You have raised three matters of concern in respect of Ms Findlay’s discharge from Priory Hospital Roehampton (PHR).
Please note that an internal learning review of Ms Findlay’s care and treatment was commissioned after we were notified of Ms Findlay’s death and recommendations for improvement were made as part of that review. The recommendations were to ensure robust hospital discharge arrangements were in place. An action plan was created to evidence implementation of the recommendations and to provide assurance of learning. We shared a copy of this action plan with your Coroners Officer, , on Thursday 9 March 2023 and I attach it as an appendix to this response. The Senior Management Team at PHR were satisfied prior to the Inquest that the necessary improvements had been made and were therefore particularly upset and disappointed to receive a Regulation 28 Report in respect of this matter.
Please find the below responses to the matters of concern that you have raised.
1. Contacting next of kin / emergency contacts at the point of hospital discharge
You have raised a concern that staff did not contact Ms Findlay’s next of kin / emergency contact at the point of her discharge from hospital.
Whilst we understand the concern, we believe that in the circumstances appropriate steps were taken by the hospital. Ms Findlay was an informal patient and she was considered to be at low risk at the point of her discharge i.e. she had made plans for the future and she was prepared to engage with staff following her discharge. It is also important to note that Ms Findlay had mental capacity to make decisions and had withdrawn consent for staff to share information with her family. Ms Findlay had provided Priory with the contact details for a friend but had specifically asked that confidential information was not divulged.
However, in the interest of learning, the PHR Hospital Director, , has shared a reminder with hospital colleagues of the requirement to notify the next of kin or emergency contact of a patient, when self-discharge is taken against medical advice, where a patient consents to this information being shared. This was discussed during a Consultants’ meeting held on Thursday 6 April 2023 and during a Clinical Governance meeting held on Thursday 20 April 2023.
2
2. Booking follow-up appointments
You have raised a concern that a follow-up outpatient appointment was not booked for Ms Findlay prior to her discharge from hospital.
This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.
3. Contacting patients following hospital discharge
You have raised a concern that Ms Findlay was not contacted until 10 days after she discharged herself from hospital
This matter was also identified as an improvement action as part of the internal learning review referenced above. Nursing and medical colleagues at the hospital have since been reminded about the requirement to make telephone contact with a patient 48 hours after discharge (unless the patient has a confirmed community mental health team/crisis recovery home treatment team appointment within 72 hours of discharge). The purpose of the telephone call is to check on the patient’s welfare and respond to any issues identified. We have already audited the provision of post-discharge telephone calls and identified significant progress: we will continue to audit this monthly, until we have three successive months of 100% compliance.
I trust that the actions outlined above will provide the assurances you seek in respect of this matter.
Ms Annabel Jean Findlay - Response to Regulation 28 Report
I write to you in response to the Regulation 28 Report dated Wednesday 1 March 2023. The report was issued following the Inquest touching the death of Ms Annabel Findlay. You have raised three matters of concern in respect of Ms Findlay’s discharge from Priory Hospital Roehampton (PHR).
Please note that an internal learning review of Ms Findlay’s care and treatment was commissioned after we were notified of Ms Findlay’s death and recommendations for improvement were made as part of that review. The recommendations were to ensure robust hospital discharge arrangements were in place. An action plan was created to evidence implementation of the recommendations and to provide assurance of learning. We shared a copy of this action plan with your Coroners Officer, , on Thursday 9 March 2023 and I attach it as an appendix to this response. The Senior Management Team at PHR were satisfied prior to the Inquest that the necessary improvements had been made and were therefore particularly upset and disappointed to receive a Regulation 28 Report in respect of this matter.
Please find the below responses to the matters of concern that you have raised.
1. Contacting next of kin / emergency contacts at the point of hospital discharge
You have raised a concern that staff did not contact Ms Findlay’s next of kin / emergency contact at the point of her discharge from hospital.
Whilst we understand the concern, we believe that in the circumstances appropriate steps were taken by the hospital. Ms Findlay was an informal patient and she was considered to be at low risk at the point of her discharge i.e. she had made plans for the future and she was prepared to engage with staff following her discharge. It is also important to note that Ms Findlay had mental capacity to make decisions and had withdrawn consent for staff to share information with her family. Ms Findlay had provided Priory with the contact details for a friend but had specifically asked that confidential information was not divulged.
However, in the interest of learning, the PHR Hospital Director, , has shared a reminder with hospital colleagues of the requirement to notify the next of kin or emergency contact of a patient, when self-discharge is taken against medical advice, where a patient consents to this information being shared. This was discussed during a Consultants’ meeting held on Thursday 6 April 2023 and during a Clinical Governance meeting held on Thursday 20 April 2023.
2
2. Booking follow-up appointments
You have raised a concern that a follow-up outpatient appointment was not booked for Ms Findlay prior to her discharge from hospital.
This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.
3. Contacting patients following hospital discharge
You have raised a concern that Ms Findlay was not contacted until 10 days after she discharged herself from hospital
This matter was also identified as an improvement action as part of the internal learning review referenced above. Nursing and medical colleagues at the hospital have since been reminded about the requirement to make telephone contact with a patient 48 hours after discharge (unless the patient has a confirmed community mental health team/crisis recovery home treatment team appointment within 72 hours of discharge). The purpose of the telephone call is to check on the patient’s welfare and respond to any issues identified. We have already audited the provision of post-discharge telephone calls and identified significant progress: we will continue to audit this monthly, until we have three successive months of 100% compliance.
I trust that the actions outlined above will provide the assurances you seek in respect of this matter.
Sent To
- Priory Hospital
Response Status
Linked responses
1 of 1
56-Day Deadline
26 Apr 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 27 September 2021, I commenced an investigation into the death of Annabel Jean Findlay who died aged 56 years’ old. The investigation concluded at the end of the inquest on 1 March 2023. The conclusion of the inquest was a short-form conclusion of suicide. The medical cause of death was determined to be fatal pressure to the neck.
Circumstances of the Death
Ms. Findlay had a history of psychiatric illness and a long history of depression, for which she was receiving support and treatment. She was an outpatient under the care of psychiatrists at the Priory Hospital, Roehampton from 7 February 2018 until 20 August 2021. She was noted as not always engaging with medical professionals and disclosed that she had been self-medicating. On 20 August 2021, Ms. Findlay was admitted as an inpatient at the Priory Hospital, Roehampton, following a referral from her General Practitioner for “various complaints”. Ms. Findlay had been taking the anti-depressant venlafaxine but this had resulted in unintended urinary retention and prior to her admission, her intake was being reduced by her treating psychiatrists. On 20 August 2021, following her admission, she was started on a different anti-depressant, vortioxetine and attended to by staff and medical professionals. On 27 August 2021, Ms. Findlay discharged herself from the Priory Hospital, Roehampton. This was despite the requests of her treating psychiatrist for her to remain so that her response to her change of medication could be monitored. At the time of discharge, no significant risks were identified and Ms. Findlay was deemed to have capacity and was deemed fit for discharge. A discharge plan was put in place. The discharge plan for Ms. Findlay included that she was to contact the hospital to make an outpatient appointment. She was also discharged with a week’s supply of medication. A discharge summary was sent to her GP.
Copies Sent To
Ms. Findlay’s emergency contact
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.