Noah Lomax
PFD Report
All Responded
Ref: 2019-0186
All 1 response received
· Deadline: 9 Oct 2019
Coroner's Concerns (AI summary)
The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.
View full coroner's concerns
1. As I made clear during the Inquest I was concerned about the adequacy of the CAMHS, GP referral form. , Noah’s GP, was inexperienced she had not completed a CAMHS referral form before. She accepted that she had not provided sufficient detail in the form. This resulted in CAMHS being unable to assess Noah’s risk and declining Noah’s referral. This in turn meant that Noah did not receive an appointment with CAMHS before his death.
The Trust’s investigation report stated that the evidence “suggests that the current referral form does not capture the information required to process referrals without delay.”
, CAMHS Clinical Lead, said that there had not been any other problems with the form with GP’s not completing them sufficiently. I am not sure how is able to be so confident about this.
I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form.
Having carefully considered the evidence I am not satisfied that steps have been put in place to ameliorate the risk identified. Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided. I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care.
The Trust’s investigation report stated that the evidence “suggests that the current referral form does not capture the information required to process referrals without delay.”
, CAMHS Clinical Lead, said that there had not been any other problems with the form with GP’s not completing them sufficiently. I am not sure how is able to be so confident about this.
I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form.
Having carefully considered the evidence I am not satisfied that steps have been put in place to ameliorate the risk identified. Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided. I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care.
Responses
Action Planned
The CAMHS team has commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning at Sheffield Clinical Commissioning Group (SCCG) for comments. The reviewed and updated form and guidance will be distributed to all General Practitioners by 12 July 2019. (AI summary)
The CAMHS team has commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning at Sheffield Clinical Commissioning Group (SCCG) for comments. The reviewed and updated form and guidance will be distributed to all General Practitioners by 12 July 2019. (AI summary)
View full response
Dear Ms Davies Noah Lomax (deceased) Regulation 28 write in response to your Regulation 28 Report to Prevent Future Deaths dated 24
2019. Under paragraph 7 Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust to consider your matter for concern and take action to prevent future deaths. The Trust sets out below its response to your matter of concern below: During the inquest into the death of Noah Lomax you expressed concerns about the adequacy of the CAMHS referral form that is used by General Practitioners You identified that our investigation report stated that the evidence 'suggests that the current referral form does not capture the information required to process referrals without delay' and that during the inquest you heard evidence that there had not been any other problems with GP's not completing them sufficiently and that redesigning the form had been considered by the Trust but was told this was not the answer. You were informed further training had been provided to General Practitioners and guidance had been attached to the referral forms to assist General Practitioners with this process_ The actions described above did not assure you that satisfactory steps have been in place to ameliorate the risk identified. You have therefore invited our Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided, which may result in a in care_ During the inquest it was confirmed that the referral guidelines were being updated with input from a General Practitioner, This has now been completed and the guidance is now in place and used. The current form will continue to be used alongside the new guidance in mitigation until the actions outlined below have been completed. The CAMHS team have commenced a review of the referral form_ and a draft form was sent to the Clinical Director for Mental Health commissioning the Sheffield Clinical Commissioning Group (SCCG), for comments This draft was reviewed by SCCG's Clinical Reference Group, which The togetriur John Somers SVS Stoetfietder ciedstsi Sarah Jones Chief Executive Stundard Chair charirv: ~urt Your May put delay being
consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form: Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners The form and guidance are currently reviewed and updated and will be distributed to all General Practitioners by 12
2019. If can be of any further assistance please do not hesitate to contact me_
2019. Under paragraph 7 Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust to consider your matter for concern and take action to prevent future deaths. The Trust sets out below its response to your matter of concern below: During the inquest into the death of Noah Lomax you expressed concerns about the adequacy of the CAMHS referral form that is used by General Practitioners You identified that our investigation report stated that the evidence 'suggests that the current referral form does not capture the information required to process referrals without delay' and that during the inquest you heard evidence that there had not been any other problems with GP's not completing them sufficiently and that redesigning the form had been considered by the Trust but was told this was not the answer. You were informed further training had been provided to General Practitioners and guidance had been attached to the referral forms to assist General Practitioners with this process_ The actions described above did not assure you that satisfactory steps have been in place to ameliorate the risk identified. You have therefore invited our Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided, which may result in a in care_ During the inquest it was confirmed that the referral guidelines were being updated with input from a General Practitioner, This has now been completed and the guidance is now in place and used. The current form will continue to be used alongside the new guidance in mitigation until the actions outlined below have been completed. The CAMHS team have commenced a review of the referral form_ and a draft form was sent to the Clinical Director for Mental Health commissioning the Sheffield Clinical Commissioning Group (SCCG), for comments This draft was reviewed by SCCG's Clinical Reference Group, which The togetriur John Somers SVS Stoetfietder ciedstsi Sarah Jones Chief Executive Stundard Chair charirv: ~urt Your May put delay being
consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form: Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners The form and guidance are currently reviewed and updated and will be distributed to all General Practitioners by 12
2019. If can be of any further assistance please do not hesitate to contact me_
Sent To
- Sheffield Children’s NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
9 Oct 2019
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
An investigation was commenced into Noah Lomax’s death on 8 August 2018 and an Inquest was opened the same day.
I concluded an inquest on 24 May 2015.
The findings of the court were as follows:
Medical Cause of death 1(a) Multiple Injuries
Conclusion: Suicide
I concluded an inquest on 24 May 2015.
The findings of the court were as follows:
Medical Cause of death 1(a) Multiple Injuries
Conclusion: Suicide
Circumstances of the Death
Noah was 15 years of age. At the beginning of July 2018 Noah’s mother was made aware of online communication between Noah and a friend in which he expressed an intention to take his own life by jumping off a bridge. Noah’s mother acted immediately upon this concern and both made an appointment for Noah to see his GP and to attend Door43 an organisation that provides emotional support for young people.
Noah’s and his mother attended the GP appointment with the specific intention to obtain help by way of a referral to CAMHS. Noah’s GP was told that he had suicidal thoughts and had plans to take his own life. Noah’s GP completed a written, non-urgent, referral to CAMHS
CAMHS processed the referral promptly but the referral contained insufficient information for a risk assessment to be performed Therefore, CAMHS closed
Noah’s referral but invited his GP to provide further information. Noah’s GP planned to use the appointment arranged on 6 August 2018 as an opportunity to obtain the further information sought by CAMHS.
Noah’s family were not notified that CAMHS had declined the referral. The Trust accepted that the process of requesting further information was not sufficiently robust and that telephone contact with the GP should have been made. This would have avoided the need for a re-referral. Had the information been known that Noah was actively making plans to take his own life CAMHS would have categorised his appointment as urgent and seen him within 2 weeks.
Assumptions were made regarding the support being offered to Noah by Door43. The Trust accepted that the actual level of support ought to have been confirmed directly between CAMHS and Door43.
The Trust accepted that the current referral form does not capture the information required to process referrals without delay.
Noah went on holiday with his father and step-mother between 22 July and 29 July 2018. Noah was not seen by CAMHS on his return.
On 1 August 2018 Noah was not open with his mother about his plans. Instead of spending the day with friends he travelled, by a pre-planned route, to Conisborough Viaduct. Sometime after 1.30pm Noah took his own life by jumping from the Viaduct.
Noah’s and his mother attended the GP appointment with the specific intention to obtain help by way of a referral to CAMHS. Noah’s GP was told that he had suicidal thoughts and had plans to take his own life. Noah’s GP completed a written, non-urgent, referral to CAMHS
CAMHS processed the referral promptly but the referral contained insufficient information for a risk assessment to be performed Therefore, CAMHS closed
Noah’s referral but invited his GP to provide further information. Noah’s GP planned to use the appointment arranged on 6 August 2018 as an opportunity to obtain the further information sought by CAMHS.
Noah’s family were not notified that CAMHS had declined the referral. The Trust accepted that the process of requesting further information was not sufficiently robust and that telephone contact with the GP should have been made. This would have avoided the need for a re-referral. Had the information been known that Noah was actively making plans to take his own life CAMHS would have categorised his appointment as urgent and seen him within 2 weeks.
Assumptions were made regarding the support being offered to Noah by Door43. The Trust accepted that the actual level of support ought to have been confirmed directly between CAMHS and Door43.
The Trust accepted that the current referral form does not capture the information required to process referrals without delay.
Noah went on holiday with his father and step-mother between 22 July and 29 July 2018. Noah was not seen by CAMHS on his return.
On 1 August 2018 Noah was not open with his mother about his plans. Instead of spending the day with friends he travelled, by a pre-planned route, to Conisborough Viaduct. Sometime after 1.30pm Noah took his own life by jumping from the Viaduct.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.