UK Inquiry Tracker

Gail Bannister

PFD Report All Responded Ref: 2018-0039

Date of Report 9 February 2018

Coroner Andrew Cox

Coroner Area Worcestershire

Response Deadline ✓ from report 6 April 2018

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 6 Apr 2018

Coroner's Concerns (AI summary)

The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered crisis communication with the care team.

View full coroner's concerns

(1) The rationale behind discharging Mrs Bannister from the HTT to CARS was that she had been seeing too many different people. It was felt that by concentrating her care in the hands of the community consultant psychiatrist and a Care Co-ordinator, who would arrange the psycho-social services she would benefit from, this would improve her treatment. The fact that the care co-ordinator did not see her frustrated and undermined this approach.

(2) During the inquest I was told that the deceased's husband tried to speak to members of the care team who were based at the Studdart Kennedy centre when a crisis developed. It took him several hours to get through. I was told there is only one phone line and that this is a known and recurring problem.

Responses

Response Worcestershire Health and Care NHS Trust

27 Mar 2018

Action Planned
Worcestershire Health and Care NHS Trust is installing a new telecommunications system with call forwarding at Studdart Kennedy House, with a survey completed and a capital bid to be submitted; interim measures include a mobile telephone for staff to contact the site/duty worker. (AI summary)

View full response

Dear Mr Cox Re: Inquest touching the death of Gail Bannister Regulation 28 report t0 prevent future dcaths rosponse Thank you for your letter dated 9 February 2018and the enclosed Regulation 28 repor; have read Your repon with great care and note the concorns (hat You raised 38 ? rosult af the coronial inquiry inlo lhe death of Gail Bannistor In your report; you highlighted the following points of concern and will respand to each in turn" The rationale behlnd discharging Mrs Bannister from the HTT to CARS was that she had becn seeing too many different poople. It was felt that by concentrating her care in the hands of the community Consultant Psychiatrist and a Care Co-ordinator; who would arrange the psycho-social serviccs she would benelit from, this would improve her treatment The fact that the Care Co-ordinator did not see her frustrated and undormined this approach; It was the expectatian of both the discharging clinicians_ ard the community Psychiatrist that & Care Co-ordinator would be frequently involved wilh Mrs Bannister_ This is also cocumented in the plan af cere set by the community Psychiatrist follcwing her appointment with Mrs Bannister on 1Bh August 2017when Ihe Co-ordinator was also in altendarce: As heard in evidence during the inquest, the Psychiatrist wa: under the impression, that following this appoirtrient weekly visits from the Care Co-ordinator were in fact taking place It is extremely concerning that it transpires that, with the exception of tho above mentioned joint appointment on 1th August 2017, no contact was made by the Care Co-ordinator with Mrs Banrister; confirm that the Trust Is addressing this matter in an appropriate Manner; am sure that you will appreciate the confidentiality obligations which {ace which mean: thai am unable to share specific details with You and other Interested Persons Chairman: Chris Rurdon Chief Exccutlve: Sarah Dugan Working together for outstanding care Way nave out Care

21 During thc inquest; [ was tald that the dereased $ husband tried to speak to members of the care team who were based at Studdart Konnedy House when a crsis developed: It took him several hours t0 through: was told that there Is only one phone line and that this Is a known and recurring problem An actizn Plan has been put In place to Install a telecommunicaticng %ystem wnich wIIll provide a digital telephone system (VOIF) This will erable call and call forwarditranster automalically An initial review of the current system has already taken place and a contractor Survey of Studdart Kennody House been agreed and funded by Worcestershire County Councii (who own the building} . This costingg survey wag undertaken on Zist and 22d March 2018, however has nolyet been received by the Trust; Itis hoped that a capital bid will be completed by the erd of April 2018 and sent to the Finance Director for approval, with work to the begin following this Unfortunately_ a date ior completion cannot yet be given 22 thi: depend upon extemal contractams; however, would like to oifer re-a83urance that Ihis malter I8 being given the atention required In thie meantime, Interim meagures have boen implemented cansisting of & mobile telephone being used by Adult Mental Health staff (o use [o contaci the sitelduty worker and communicaticn has been given t0 all staff to advise them cf this interim measure and Ihe appropriate contact telephone numbers to Vbe. trust Ihat lhe foregoing has Bdequstely addressed the Regulation 28 report issued subsequent to Ihe inquest Into the death cf Gail Bannister; Should you require any progress update: or clarincalion In relation t0 this matter; please do not hesitate to ask. confrm that have not forwarded # CoPy cf tnis response to any other Interestod Person and vould tnerefore be grateful il you could do $0 a5 appropriate also confirm that the Trust is content for bcth the regulation 28 report and the rosponse l0 b# released Dr published should the Chiel Caroner wish_ Ycurs eincerely Sarah Dugan Chiel Executive Chairman; Chris Burdlon Chlef Executive: Sarah Dugan Working together for outstanding care get waiting ha; will

Sent To

Worcester Health and care Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 6 Apr 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 20/9/17, I commenced an investigation into the death of Gail Ann Bannister then aged 60. The investigation concluded at the end of the inquest on 8 February 2018. The conclusion of the inquest was suicide, the medical cause of death being 1a) hanging.

Circumstances of the Death

Mrs Bannister had a long history of a fluctuating mental health condition. In March 2017, she was noted to suffer a deterioration following the illness and subsequent death of her father. She was seen by her GP and then referred to CARS and onto the HTT service. She was referred back to CARS in early August 2017. A Care Co-ordinator had been appointed on 20 July to facilitate psycho-social services that it was felt Mrs Bannister required and to provide continuity in her care. Her care co-ordinator did not see her between the date of her appointment and Mrs Bannister's death two months later.