Thomas King
PFD Report
All Responded
Ref: 2020-0207
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
All 1 response received
· Deadline: 28 Jan 2021
Coroner's Concerns (AI summary)
Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.
View full coroner's concerns
(1) It was the evidence of the author of the EPUT Root Cause Analysis Investigation Report, , that whilst all the other EPUT teams that came into contact with Mr King, such as the Mental Health Liaison Team and the Street Triage Team, used the same software called Mobius with which to record, access and share important information and developments regarding Mr King, one Team, namely the Health and Justice Team did not use this software and instead used software that was incapable of being accessed by the other teams. A consequence of this was that the other teams were wholly unaware of crises and other important information regarding Mr King’s mental health that were known to the Health and Justice Team.
(2) Whilst it was the view of the RCA author that in Mr King’s case such an obstacle to the sharing / accessing of important information did not have a direct bearing on the outcome for Mr King, she did expressly state, and I share this concern, that there is the potential for the wellbeing and lives of other individuals to be jeopardised where important information and / or crises are known to and recorded by the Health and Justice Team but unknown to all the other relevant Teams. There is the potential for the risk of harm to self and others, including death, to be inaccurately assessed and managed where the assessor does not have access to the full picture.
(3) The RCA author was not aware as to why the Health and Justice Team had different software to Mobius or why it was not capable of integration with Mobius, but she felt, and I agree, that action should be taken, if it has not already happened, to explore this issue and to implement a solution.
(2) Whilst it was the view of the RCA author that in Mr King’s case such an obstacle to the sharing / accessing of important information did not have a direct bearing on the outcome for Mr King, she did expressly state, and I share this concern, that there is the potential for the wellbeing and lives of other individuals to be jeopardised where important information and / or crises are known to and recorded by the Health and Justice Team but unknown to all the other relevant Teams. There is the potential for the risk of harm to self and others, including death, to be inaccurately assessed and managed where the assessor does not have access to the full picture.
(3) The RCA author was not aware as to why the Health and Justice Team had different software to Mobius or why it was not capable of integration with Mobius, but she felt, and I agree, that action should be taken, if it has not already happened, to explore this issue and to implement a solution.
Responses
Action Taken
The Trust has implemented Tiani Health Information Exchange (HIE), an interoperable application that allows clinicians to view patient data from across systems, including the Health and Justice Service's Exelicare system. All clinical staff in the Trust now have access to the HIE. (AI summary)
The Trust has implemented Tiani Health Information Exchange (HIE), an interoperable application that allows clinicians to view patient data from across systems, including the Health and Justice Service's Exelicare system. All clinical staff in the Trust now have access to the HIE. (AI summary)
View full response
Dear Mr Brookes,
I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 15th October 2020, which was issued following the inquest into the death of Mr Thomas King.
I would like to begin by extending my deepest condolences to the family of Mr King. This has been an extremely difficult time for them and I hope that my response provides the family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issue of concern raised in your report.
In response to the matter of concern regarding the potential for the wellbeing and lives of other individuals to be jeopardised where important information and/or crises are known to and recorded by the Health and Justice Team but are unknown to all other relevant teams as they do not have access to the same casenote recording systems. I can confirm that the Health and Justice Service use a recording system called Exelicare which was procured by NHS England. We are contracted by NHS England to provide this service and as part of the contract we are required to use this system to record patient information.
The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE.
I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust’s top priority.
I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 15th October 2020, which was issued following the inquest into the death of Mr Thomas King.
I would like to begin by extending my deepest condolences to the family of Mr King. This has been an extremely difficult time for them and I hope that my response provides the family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issue of concern raised in your report.
In response to the matter of concern regarding the potential for the wellbeing and lives of other individuals to be jeopardised where important information and/or crises are known to and recorded by the Health and Justice Team but are unknown to all other relevant teams as they do not have access to the same casenote recording systems. I can confirm that the Health and Justice Service use a recording system called Exelicare which was procured by NHS England. We are contracted by NHS England to provide this service and as part of the contract we are required to use this system to record patient information.
The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE.
I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust’s top priority.
Sent To
- Essex Partnership University NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
28 Jan 2021
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 7/5/2020 I commenced an investigation into the death of THOMAS JEFFERY KING (aged 27). The investigation concluded at the end of the inquest on 9/10/2020 The conclusion of the inquest was: Medical cause of death: I a Asphyxia b Hanging CONCLUSION: SUICIDE
Circumstances of the Death
On 28th April 2020 Mr King was found hanging at his home address in an outside toilet. Paramedics were called but sadly Mr King’s death was confirmed at the scene. Police attended and found no evidence to suggest third party involvement in the death. The Court found that Mr King intentionally ended his own life. He had acted impulsively and whilst suffering from very low mood. The Court heard that he had a history of poor mental health which had often deteriorated in moments of crisis linked to his failed relationship with his partner who had obtained a restraining order against him. He had been arrested and sentenced for several breaches of this order (including custody). He also struggled with bereavement following the death of his father. He had been known to mental health services for many years but his contact increased in the months preceding his death whilst coming into contact with the criminal justice system following arrests for the breaches.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.