Conall Gould
PFD Report
All Responded
Ref: 2017-0458
All 1 response received
· Deadline: 23 Nov 2017
Coroner's Concerns (AI summary)
The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust lacked a policy requiring written confirmation. This created a significant risk of missed appointments and inadequate care review.
View full coroner's concerns
At the time of discharge from Holywell Hospital on the 30th January 2017 Mr: Gould had been referred to the community mental health team for a 7 day review and had been given an appointment on the 2"d February 2017. There is no evidence in the Trust'$ records that the time, date and location of this appointment was given to Conall or his parents_ The evidence 0= [Consultant Psychiatrist; who saw Conall and his father on the 30"h January 2017 was that he anticipated that the discharge nurse would tell Conall and his mother or father, as his carers, the date of his review at the point of discharge as this is the usual practice_ Mr. Gould; Conall's father, gave evidence that not only were he and his wife not told verbally of the appointment nor were they given any written information about it: on a previous discharge from an inpatient stay at another Trust had been given a letter setting out the appointment arrangements for his son following discharge_ Conall was 21 at the time of his discharge on the 30" January and his parents had taken a very active role in his care: If they had been aware of the appointment they would have made every effort to secure Conall' s attendance, as it was,believing there_to be no plan for follow Up,they did not prevent him from day being travelling to Birmingham for a period ofrest with relatives (during which time he took the fatal overdose of MDMA) The evidence of who conducted the RCA was that the Trust does not have protocol or policy stipulating the arrangements for notifying services users and their carers of follow up arrangements on discharge and current practice does not require written confirmation of follow up arrangements to be given to the service user or their carers The system currently creates a risk that services users and their carers will not be aware of follow up appointments and therefore may not attend giving rise to a danger that opportunities to review the service user' $ condition and treatment will be lost_
Responses
Action Taken
The Northern Health and Social Care Trust has introduced a requirement for written confirmation of follow-up appointments and contact numbers to be provided to patients and, with consent, their relatives/concerned others upon discharge from hospital, documented in the Integrated Care Protocol. (AI summary)
The Northern Health and Social Care Trust has introduced a requirement for written confirmation of follow-up appointments and contact numbers to be provided to patients and, with consent, their relatives/concerned others upon discharge from hospital, documented in the Integrated Care Protocol. (AI summary)
View full response
Dear Ms Hunt Mr Conall Patrick Gould Inquest held on 26 September 2017, Regulation 28 Report to Prevent Further Deaths Firstly, please accept my sincere apologies for the delay in this response to you: In relation to the matters of concern raised by you during the Inquest held into Conall's death, can now inform you of the actions the Trust has made to strengthen systems and processes of care to support patients and their families on discharge from hospital. The Trust has introduced into the Integrated Care Protocol (the in-patient clinical documentation record of the multi-disciplinary treatment team) a requirement for all patients, when being discharged from hospital, to receive written confirmation of their 7 follow-up appointment with relevant telephone contact numbers if they require assistance in the immediate days following discharge; This protocol also directs that a relativelconcerned other, identified by the patient; will also be provided with this written information when consent to do so has been given by the patient: Under the heading 'Discharge Process' on p5 section 3 has been amended in reference to the information given to the patient on discharge and section 4 has been added in reference to the carer and the information that should be shared with them, with the agreement of the patient In addition, on page 78, the Discharge Care Plan has been amended significantly to ensure both the patient and, if acceptable to the patient; the carer; are given a copy of the Discharge Care plan, Support plan and list of medication. The Trust believes this action adds a level of robustness to the existing discharge processes and addresses the concerns raised and have attached templates of the documentation now provided to all patients. would wish to thank you for raising this matter and would also advise it is planned that this protocol will be shared with Trusts across Northern Ireland at a workshop to be held on 6 June 2018, Trust Headquarters, Bretten Hall, Antrim Area Hospital, Bush Road, Antrim BT41 2RL Phone: 028 9442 4321 Email: oscar donnelly@northerntrust hscni net Ms day
Sent To
- Northern Health and Social Care Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Nov 2017
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 23/05/2017 commenced an investigation into the death of Conall Patrick Gould: The investigation concluded at the end of an inquest on 26th September 2017. The conclusion of the inquest was that Mr. Gould' s death was drug related:
Circumstances of the Death
Conall Patrick Gould died on the 13th February 2017 at the Queen Elizabeth Hospital in Birmingham having been admitted earlier that after witnessed to behave erratically and then collapse: Conall had a diagnosis of a delusional disorder, for which he had received inpatient treatment; and a history of drug: When last reviewed prior to discharge from inpatient psychiatric care at Holywell Hospital on the 3Oth January 2017 he had maintained a positive outlook and insisted that his most recent overdose was recreational and without any intention to cause himself harm. Following his discharge his behaviour did not give his family cause for concern that he would attempt suicide: Following a post mortem the medical cause of death was determined to be: 1 (a) ECSTACY USE
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
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Prevent discharge of hospitalised children with concerns until home is safe
Laming Inquiry
Care and discharge planning
Require consultant or paediatrician permission for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Require documented future care plan for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.