Joanne Richardson
PFD Report
All Responded
Ref: 2018-0134
All 1 response received
· Deadline: 26 Aug 2018
Coroner's Concerns (AI summary)
Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed patient care.
View full coroner's concerns
1_ During the inquest evidence was heard that: Mrs Richardson was under the care of the Dorset Healthcare University Foundation Trust (DHUFT) in relation to her mental health. Her latest period of treatment began in June 2017_ She was under the care of the Community Mental Health Team (CMHT) from that time until the time of her death o the 26th September 2017. The CMHT had referred her to the West Dorset Steps to Wellbeing Service for therapy: ii _ She was assessed by the Psychiatrist from the CMHT on the 13th July 2017 , 8th August 2017 and 23rd August 2017 . The Psychiatrist left the Trust and her case was then managed by Nurse Prescriber who assessed her on the 19th September 2017_ these assessments, her risk of harm was deemed to be low_ iii . She was reviewed by the Steps to Wellbeing Service on the 21s August 2017 when she was in low mood and had thoughts, but no plans, of ending her life The team felt that her risk was too high for treatment by the Service and therefore intended to refer her back to CMHT. Mrs Richardson was only advised of this in writing in a letter dated the 21st September. iv The details of that assessment were never referred to the CMHT. were therefore not aware of how she presented or the risk assessment made by the Steps to Wellbeing Service. This information could have been very valuable to those in the CMHT who assessed her on the 23rd August and 19th September. Evidence was given that some of the Steps to Wellbeing Service have access to DHUFT records, namely RIO records, but not all of them do. Evidence was further given that they do not write entries in these records. Those carrying out assessments therefore are not to have access to all information available to DHUFT in relation to the patient:
vi. Further on the 28th August 2017, Mrs Richardson contacted the Crisis Team within DHUFT stating that she had suicidal thoughts of ending her life by hanging: A call was made from the Crisis Team to the
vi. Further on the 28th August 2017, Mrs Richardson contacted the Crisis Team within DHUFT stating that she had suicidal thoughts of ending her life by hanging: A call was made from the Crisis Team to the
Responses
Action Taken
Administrators now check both electronic patient information systems for referrals, and read-only access is available to administrators and team leads. A new referral inbox is used to share urgent risk information. The need to act on information has been reinforced within the CMHT, and learning has been disseminated to all CMHTs. (AI summary)
Administrators now check both electronic patient information systems for referrals, and read-only access is available to administrators and team leads. A new referral inbox is used to share urgent risk information. The need to act on information has been reinforced within the CMHT, and learning has been disseminated to all CMHTs. (AI summary)
View full response
Dear Mrs Griffin Re: Inquest touching the death of Joanne Elizabeth Richardson (deceased) write to you further to the above mentioned Inquest which concluded on 25th April 2018 when you raised concerns and the Regulation 28 Report dated 8th May 2018. You raised three concerns_ The first concern was that, critical patient information between the Trust's to Wellbeing Service (S2W) in West Dorset and the Trusts Community Mental Health Team (CMHT) had not been shared. Secondly that patient information is recorded in two different electronic patient information systems and that not all staff have access or regularly review information in each of these systems_ Thirdly that Mrs Richardson had not been followed up in timely manner by the CMHT, after making contact with the Crisis Team: You requested review of the policies regarding communication between teams, in particular between the CMHT and S2W: We have reviewed our processes and policies regarding communication and joined up working between CMHTs and S2W services alongside relevant legislation and guidance. Currently administrators check both electronic patient information systems IAPTus for S2W for all referrals received by the CMHTs and Rio for SZW and CMHT teams to see if the patient is known to either service_ Read only access both systems are available to administrators and team leads_ If the patient has history with local mental health services this information is copied by an administrator onto the SZW clinical notes and Better Every Our vision is to lead and inspire through excellence, compassion and expertise in all we do Steps for Day
makes this available to the allocated assessing clinician, prior to them assessing the patient: After the assessment, copy of the assessment letter (summarising presenting problems, agreed treatment plan, risk summary) is copied to the other teams who are involved with the patient. significant changes to the treatment plan that take place during contacts with teams are communicated to the other teams involved. It is also standard practice that at the of discharge, for a patient who is under the care of both services for a discharge letter to be sent to the other team and GP. We have reinforced the expectation that; when a patient is being seen by both teams, discussion is had between SZW and CMHT clinicians, to discharge to agree an appropriate discharge plan. Furthermore, we have reinforced the expectation that treatment decisions are communicated to patients face to face or over the telephone in order to allow collaboration and feedback These decisions can then be formalized in a written letter to the patient; but this should only happen after a discussion has been held with the patient and other team: In addition to the communication processes described above we introduced the following measures to aid closer working between teams. On IAPTus (S2W) label has been identified that will be a visual aid on the personal information page of the record indicating that patient is also known to the CMHT. The Rio (CMHT) system does not have this functionality. However; a report has been developed that identifies patients who are under the care of both services_ If there is a significant change to a client's risk, indicating that there is a significant risk of harm, the allocated clinician will share this information with the other service in a timely manner; by telephone in the first instance If it has not been possible to speak via telephone then this information will be shared via email using the team referral inbox that is screened daily_ This will be used to share urgent information pertaining to client's risk and then be uploaded to Rio or IAPTus respectively The CMHT hold weekly multidisciplinary team meetings to review cases S2W practitioner is able to phone into a set slot at a CMHT team meeting. This enables case discussions and review of risks for those people who are under the care of both services_ Any discussions will be documented in the CMHT team meeting minutes and both clinical systems With regard to your concern about timely follow-up, our Crisis Teams inform CMHTs by email when have had contact with one of their patients: The Root Cause Analysis review highlighted that there was a failure to record the CMHT assessment and care plan in response to receiving information about Mrs Richardson's contact with the CHTT. Better Every Our vision is to lead and inspire through excellence, compassion and expertise in all we do Any point prior they Day
Emails from the CHTT are sent to CMHT clinicians involved in the patient's care and to generic CMHT account that is monitored by the administration team: ensure that clinical member of the team is aware of the message_ The need to act on such information and to document decisions on the electronic record has been reinforced within the CMHT involved through discussion of this omission in care. This learning has been disseminated to all CMHTs across the Trust hope that the actions outlined provide assurance that the Trust has investigated this matter thoroughly, communicated this learning and new processes to staff;, and introduced additional measures to ensure that communication of clinical and risk information between CMHTs and SZW in Dorset is reliable, clear and timely: If you have any queries at all, please do not hesitate to contact my office
makes this available to the allocated assessing clinician, prior to them assessing the patient: After the assessment, copy of the assessment letter (summarising presenting problems, agreed treatment plan, risk summary) is copied to the other teams who are involved with the patient. significant changes to the treatment plan that take place during contacts with teams are communicated to the other teams involved. It is also standard practice that at the of discharge, for a patient who is under the care of both services for a discharge letter to be sent to the other team and GP. We have reinforced the expectation that; when a patient is being seen by both teams, discussion is had between SZW and CMHT clinicians, to discharge to agree an appropriate discharge plan. Furthermore, we have reinforced the expectation that treatment decisions are communicated to patients face to face or over the telephone in order to allow collaboration and feedback These decisions can then be formalized in a written letter to the patient; but this should only happen after a discussion has been held with the patient and other team: In addition to the communication processes described above we introduced the following measures to aid closer working between teams. On IAPTus (S2W) label has been identified that will be a visual aid on the personal information page of the record indicating that patient is also known to the CMHT. The Rio (CMHT) system does not have this functionality. However; a report has been developed that identifies patients who are under the care of both services_ If there is a significant change to a client's risk, indicating that there is a significant risk of harm, the allocated clinician will share this information with the other service in a timely manner; by telephone in the first instance If it has not been possible to speak via telephone then this information will be shared via email using the team referral inbox that is screened daily_ This will be used to share urgent information pertaining to client's risk and then be uploaded to Rio or IAPTus respectively The CMHT hold weekly multidisciplinary team meetings to review cases S2W practitioner is able to phone into a set slot at a CMHT team meeting. This enables case discussions and review of risks for those people who are under the care of both services_ Any discussions will be documented in the CMHT team meeting minutes and both clinical systems With regard to your concern about timely follow-up, our Crisis Teams inform CMHTs by email when have had contact with one of their patients: The Root Cause Analysis review highlighted that there was a failure to record the CMHT assessment and care plan in response to receiving information about Mrs Richardson's contact with the CHTT. Better Every Our vision is to lead and inspire through excellence, compassion and expertise in all we do Any point prior they Day
Emails from the CHTT are sent to CMHT clinicians involved in the patient's care and to generic CMHT account that is monitored by the administration team: ensure that clinical member of the team is aware of the message_ The need to act on such information and to document decisions on the electronic record has been reinforced within the CMHT involved through discussion of this omission in care. This learning has been disseminated to all CMHTs across the Trust hope that the actions outlined provide assurance that the Trust has investigated this matter thoroughly, communicated this learning and new processes to staff;, and introduced additional measures to ensure that communication of clinical and risk information between CMHTs and SZW in Dorset is reliable, clear and timely: If you have any queries at all, please do not hesitate to contact my office
Sent To
- Dorset Healthcare University Hospital NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
26 Aug 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 the 4th October 2017, an investigation was commenced into the death of Joanne Elizabeth Richardson, born on the 3rd February 1962. The investigation concluded at the end of the Inquest on the 25th April 2018. The Medical Cause of Death was: la Hanging The conclusion of the Inquest_was suicide
Circumstances of the Death
On the 26th September 2017 the deceased, who was known to suffer with mixed anxiety and depressive disorder , was found suspended by ligature which was attached around the leg of a bed and passed through the bannister of the staircase at her home address at
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.