Maureen Campbell-Scott
PFD Report
Partially Responded
Ref: 2018-0090
Coroner's Concerns (AI summary)
A referral was sent to the wrong team and then lost, causing a four-month delay in assessment. There were also delays in delivering clinic letters to the GP, and prescribing did not always follow the psychiatric team's directions.
View full coroner's concerns
(1) The GP had sent the referral to the wrong team of the mental health trust: The referral then got lost between the receiving team and the correct team (the older age mental health team): This resulted in a 4 month delay in Maureen Campbell-Scott receiving an assessment: (2) There were often delays (in excess of 14 days) in the delivery to the GP of clinic letters from the mental health trust: Often, the clinic letters contained requests for the GP to make changes to medication.
(3) The prescribing by the GP did not always follow the direction given by the psychiatric team: (4) In times of acute mental health crisis, medication is often rapidly changed/supplemented: Mrs Campbell-Scott had 7 changes in her medication regime between 21 November 2016 to 23 February 2017 It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist team: (5) At the time of the Inquest hearing, there had been no joint meeting between the mental health trust and the GP practice to consider the best way forward in terms of referrals to the service; prescribing during times of dynamic medication changes and general communication between the GP the psychiatrist.
(6) It is accepted that the concerns in this case are unlikely to be restricted to the Fullwell Cross Surgery Ifa joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices_ bag " and
(3) The prescribing by the GP did not always follow the direction given by the psychiatric team: (4) In times of acute mental health crisis, medication is often rapidly changed/supplemented: Mrs Campbell-Scott had 7 changes in her medication regime between 21 November 2016 to 23 February 2017 It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist team: (5) At the time of the Inquest hearing, there had been no joint meeting between the mental health trust and the GP practice to consider the best way forward in terms of referrals to the service; prescribing during times of dynamic medication changes and general communication between the GP the psychiatrist.
(6) It is accepted that the concerns in this case are unlikely to be restricted to the Fullwell Cross Surgery Ifa joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices_ bag " and
Responses
Action Planned
NELFT has been liaising with Fullwell Cross Medical Centre and Redbridge CCG and progress has been made to address concerns and they are reconvening a meeting with primary care colleagues to discuss prescribing of medication to shared patients. (AI summary)
NELFT has been liaising with Fullwell Cross Medical Centre and Redbridge CCG and progress has been made to address concerns and they are reconvening a meeting with primary care colleagues to discuss prescribing of medication to shared patients. (AI summary)
View full response
Dear Ms Persaud RE: Regulation 28 in the case of MC-S, NELFT and Fullwell Cross Medical Centre refer to the Regulation 28 dated 28th March 2018 in relation to the sad death of Maureen Campbell-Scott. Please note that NELFT have been liaising with colleagues from both, Fullwell Cross Medical Centre and Redbridge CCG in regards to the action plan to address the issues raised in the Regulation 28 report: We have made progress in regards to completion of the actions and there remain only two actions yet to be completed by NELFT alone: have attached the latest version of the action plan for your information: understand thatl Fullwell Cross Practice Manager, has also returned the action plan to you to evidence progress, which NELFT are grateful for: We understand that he has made a note on the action plan regarding there yet to be an agreement between Primary Care colleagues and NELFT Psychiatrists in regards to prescribing of medication changes and titration of drugs. We have had two meetings with the Fullwell Cross Practice and believe that we had agreed a process regarding the prescribing of medication to our shared patients. It was only on Tuesday of this week that we were informed that the practice had some late reservations about this specific aspect of the joint action plan: As such we are reconvening a meeting with Primary Care Colleagues to discuss the position further and agree a way forward. We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing whereas our clinicians advise this is not practical for a number of reason, these broadly the following: Risks to patient safety. The GP has the overview of the entire patient's medication. If the mental health medication is prescribed in isolation there is a significant patient safety risk: Medications may have interactions and contraindication that we as potential prescribers may be unaware ofas we do not have an overview: to advanced frailty of many of the patients, cannot get their own prescription or do not have family members who are able to do it for them. NELFT do not have arrangements with community pharmacists to ensure medication is provided: Many patients under the Older Adult Mental Health Team do not have capacity; therefore prescribing via FP1O is not feasible: Many of our patients use compliance aids like dosett box/blister packs therefore the medication needs to be organised via the GP. NELFT are unable to facilitate this via local pharmacists Many of our patients are in care homes, nursing homes and sheltered accommodation who will not accept a prescription via the FP1O, as this would need to be filled by a community pharmacist. Chair: Joe Fielder Chief executive: John Brouder E disability confident
EMPLOYER Wing Way good duty, being Due they
We have already agreed to provide personal contact details of NELFT Consultant's to GPs for additional support and this action is already in place to allow GP's to access advice regarding the management of people who have mental health problems: NELFT attended a very successful event with all Redbridge GP's last week, where our staff did a series of table presentation to the GP'. The theme was around mental health services and the crisis care pathway: We believe this will aid our future joint working with GP's within the borough: The event was coordinated by who is the BHR CCG Lead GP for Mental Health: At the event he briefed GP' s regarding future communication methods that all communication will move to being electronic in line with the action plan in relation to this regulation 28. apologise for the slight delay in forwarding the action plan, but as stated above this was due to the concerns raised by the practice: You may be assured that as an organisation NELFT and our officers will not leave the matter here, but continue to do all that we can to ensure that the gap in responsibility is closed.
EMPLOYER Wing Way good duty, being Due they
We have already agreed to provide personal contact details of NELFT Consultant's to GPs for additional support and this action is already in place to allow GP's to access advice regarding the management of people who have mental health problems: NELFT attended a very successful event with all Redbridge GP's last week, where our staff did a series of table presentation to the GP'. The theme was around mental health services and the crisis care pathway: We believe this will aid our future joint working with GP's within the borough: The event was coordinated by who is the BHR CCG Lead GP for Mental Health: At the event he briefed GP' s regarding future communication methods that all communication will move to being electronic in line with the action plan in relation to this regulation 28. apologise for the slight delay in forwarding the action plan, but as stated above this was due to the concerns raised by the practice: You may be assured that as an organisation NELFT and our officers will not leave the matter here, but continue to do all that we can to ensure that the gap in responsibility is closed.
Sent To
- North East London Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
23 May 2018
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 18/07/2017, commenced an investigation into the death of Maureen Anne CAMPBELL-SCOTT: The investigation concluded at the end of the inquest 26th March 2018. The conclusion of the inquest was a narrative conclusion: Maureen Campbell-Scott suffered fatal injuries when she fell from the ledge of the Exchange Shopping Centre. She died as @ result of her own actions, but the evidence does not reveal her intention at the time of the fall:
Circumstances of the Death
Maureen Campbell-Scott had suffered for many years from depression and anxiety She suffered a decline in her mental state in around April 2016. The GP referred her to the mental health services on 29 April 2016. There was a in the correct team processing the referral: She was assessed by the older age mental health team in September 2016, but was not considered to meet the criteria for specialist mental health services at that time: She came under the care of the specialist mental health services in November 2016 following her husband's contact with Mental Health Direct_ She remained under the care of the specialist mental health services until she passed away: Medication that she had remained stable on for many years, appeared no longer to be working for her. Her medication regime was therefore changed by her consultant psychiatrist. There were some delays in communicating requested medication changes to the GP Directions provided by the mental health team to the GP,in relation to prescription of mental health medication were not fully complied with: It is not
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.