(1) In her statement provided for the purposes of the inquest, FH’s consultant psychiatrist listed the medications prescribed to FH at the time of her death but made no reference to the Oromorph. During the course of her oral evidence she confirmed that, at the time of her last review of FH in April 2020, she was entirely unaware that she had been prescribed this powerful morphine-based pain killer for a number of months. She also confirmed that had she known of the prescription for that medication it would have affected her risk assessment, given LH’s continuing misuse of alcohol. She told the court that it was (and remains) her usual practice to rely entirely on the information regarding medication (including dosage and frequency) provided by the patient, even in telephone only consultations. She stated that she would only rarely (and certainly not routinely) check the accuracy of the account provided by obtaining a list of medication from the GP or other clinical records.

Although not causative in respect of FH’s death, I am concerned that the practice of relying entirely on a patient’s account of current medication, in circumstances where significant mental health issues are often involved (including where there is chronic substance and/or alcohol misuse) gives rise to a serious risk of future deaths. As was accepted by the witness, any risk assessments, care plan reviews or further prescribing of (or alteration to) a medication regimen may in such circumstances be predicated upon incomplete, inaccurate and potentially dangerously misleading information. In my view the risk of future deaths is clear.

(2) Further, oral evidence from a senior EPUT witness confirmed that the Trust could not, as the electronic systems were presently configured, readily access information held by GP practices regarding individual patients (and vice versa). It appeared that this evidence was provided by way of an explanation as to why accurate and up to date medication/prescribing information was not routinely obtained by clinicians in advance of reviews of patients. Absent any other system for ensuring swift and accurate information transfer between primary and secondary care providers, then the continuation of a state of affairs where a consultant psychiatrist is undertaking a review of a mental health patient but does not have access to a definitive record of the medication presently being taken by that patient (and/or their concordance with prescribed medication) gives rise to a conspicuous risk of future deaths. The EPUT witness suggested that this was a matter for the Clinical Commissioning Group (CCG) to address.

(3) Issues regarding the necessity for access to (and adequate time for the consideration of) medical records including prescriptions for and concordance with medication in advance of mental health reviews undertaken by responsible clinicians has been raised in relation to mental health related death in Essex previously. I am concerned that the evidence from FH’s inquest indicates that such matters remain unresolved.