Paul Price
PFD Report
All Responded
All 2 responses received
· Deadline: 14 Nov 2018
Coroner's Concerns (AI summary)
Critical delays in information sharing between mental health services and GPs, due to incompatible IT systems and communication failures, risk patient care and medication management.
View full coroner's concerns
1. Paul was seen for a full assessment on 04/05/18. The summary of that attendance in a letter was not received by the GP until 29/05/18. In the meantime Paul had attended his GP with ongoing concerns about his mental health and requesting further medication. The delay in receiving critical information about vulnerable patients could put them a risk and result in over prescribing medication. In addition I was told that the IT systems for Birmingham and Solihull Mental Health Trust and the GPs are incompatible meaning that letters have to be faxed or posted causing further delay.
2. A call was made to the Mental Health team on 01/06/18 raising a concern about Paul’s mental health. The caller was told that the computer systems were down and the mental health team would call back – they did not call back. There is concern that staff are not accurately recording information and arranging follow-up.
2. A call was made to the Mental Health team on 01/06/18 raising a concern about Paul’s mental health. The caller was told that the computer systems were down and the mental health team would call back – they did not call back. There is concern that staff are not accurately recording information and arranging follow-up.
Responses
Sent To
- Birmingham and Solihull Mental Health Trust
Response Status
Linked responses
2 of 1
56-Day Deadline
14 Nov 2018
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 20/06/2018 I commenced an investigation into the death of Paul Price. The investigation concluded at the end of an inquest on 18th September 2018. The conclusion of the inquest was Open.
Circumstances of the Death
The deceased had a history of depression and anxiety. He first exhibited suicidal ideation in March 2018. He was assessed by the mental health team. He had a full assessment by a consultant on 04/05/18 and was prescribed further medication. He presented to the emergency department at City Hospital on 15/05/18 having taken an overdose. He was then assessed by his GP on 16/05/18 when he denied any suicidal ideation and said his actions had been a cry for help. His GP spoke to him on 21/05/18 when he seemed better. On 01/06/18 the window in his room was found to be damaged and was repaired and closed. The mental health team were contacted as there were concerns about his wellbeing. The mental health team advised their systems were down and they would ring back however no one rang back. There were no concerns about him on 02/06/18 and 03/06/18. On 04/06/18 he was found on the ground outside his room having fallen from the window. His intentions at the time are unclear. He was taken to the Queen Elizabeth hospital where he was pronounced deceased at 13.06.
Following a post mortem the medical cause of death was determined to be: MULTIPLE INJURIES
Following a post mortem the medical cause of death was determined to be: MULTIPLE INJURIES
Copies Sent To
NHS England, CQC and the CCG
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.