Guy Robinson
PFD Report
1 of 1 responses identified
Ref: 2015-0432
All 1 listed response identified
· Deadline: 7 Jan 2016
Coroner's Concerns (AI summary)
The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists with no inpatient clinical psychology access, disadvantaging vulnerable patients.
View full coroner's concerns
1. The ‘AWOL’ protocol was not applied appropriately/in a timely manner and during the course of the evidence it became apparent that some of clinicians lacked familiarity with the protocol and process. Whilst the Trust has taken steps to ensure that the protocol has been discussed with all staff based on the ward in question, action has not been taken Trust-wide to ensure that all staff are fully familiar with this policy.
2. Clinical Psychology Service - the only access afforded to a Clinical Psychologist depends upon three pre-requisites being met - i) discharge ii) to a fixed abode iii) onward referral by the Community Mental Health Team. There is no inpatient Clinical Psychology facility and no ability for hospital clinicians to refer a patient directly. This is a significant service gap and potentially prejudices/puts at risk some of the most vulnerable people e.g. those who are of no fixed abode.
2. Clinical Psychology Service - the only access afforded to a Clinical Psychologist depends upon three pre-requisites being met - i) discharge ii) to a fixed abode iii) onward referral by the Community Mental Health Team. There is no inpatient Clinical Psychology facility and no ability for hospital clinicians to refer a patient directly. This is a significant service gap and potentially prejudices/puts at risk some of the most vulnerable people e.g. those who are of no fixed abode.
Responses
Action Taken
The Trust reviewed and revised the Absence Without Leave (AWOL) policy, including additional guidance and a flowchart, and implemented it Trust-wide on April 1, 2015; Psychological therapies are available on the ward via referral from a Consultant Psychiatrist or nursing staff. (AI summary)
The Trust reviewed and revised the Absence Without Leave (AWOL) policy, including additional guidance and a flowchart, and implemented it Trust-wide on April 1, 2015; Psychological therapies are available on the ward via referral from a Consultant Psychiatrist or nursing staff. (AI summary)
View full response
Dear Ms Hashmi, Re: GUY ROBINSON (Deceased), DOB: 3111011982 Thank you for your Regulation 28 Report, dated the 12 th November 2015, and for bringing to my attention the concerns that you had after hearing all the evidence. Your concerns have been reviewed in line with the stipulated timescales. I list below the Trust response to the two points you raised.
1. The ‘AWOL’ protocol was not applied appropriately I in a timely manner and during the course of the evidence it became apparent that some of the clinicians lacked familiarity with the protocol and process. Whilst the Trust has taken steps to ensure that the protocol has been discussed with the staff based on the ward in question, action has not been taken Trust wide to ensure that all staff are fully familiar with this police. Response: Following the Trust’s investigation, the Absence without Leave (AWOL) Policy was reviewed and additional guidance included in relation to actions that should be taken when a person goes AWOL. This policy was initially piloted within the Trust’s Mental Health In-Patient Unit at Tameside General Hospital. The revised policy was implemented Trust wide on the 1st April 2015. I have been assured by both In-Patient Service Manager for the North (Oldham/Rochdale/Bury) and the South (Stockport/Tameside) that this information has been shared and staff are familiar with the policy. In order to assist staff a flowchart has been produced as part of the policy, which also explains to staff when to contact the police to inform them of a patient who has not returned from leave (attached).
2. Clinical Psychology Service
— the only access afforded to a Clinical Psychologist depends upon three pre-requisites being met; I) discharge ii) to a fixed abode iii) onward referral by the Community Mental Health Team. There is no In-Patient Clinical Psychology facility and no ability for hospital clinicians
to refer a patient directly. This is a significant service gap and potentially prejudices/puts at risk some of the most vulnerable people, e.g. those who are no fixed abode. Response:
- There is access to Psychological Therapies on the ward, which takes the form of consultation, assessment and formulation and supervision for staff who are providing psychologically informed support to patients.
- A Consultant Psychiatrist or nursing staff can refer an in-patient for Psychological Therapies if appropriate.
- It is not necessary for a service user to have a home address in order to access Psychological Therapies whilst an in-patient, however once discharged they would have to have access to an address or a telephone in order to be contactable for future appointments.
- It is a requirement that secondary care patients accessing Psychological Therapies are open to a Care Coordinator, this is in order that individuals undergoing therapy may raise difficult and challenging issues, have a support network and crisis plan in place whilst doing exploratory therapy so that any increased risk can be managed. I hope this response assures you that the Trust takes seriously any concerns that you raised.
1. The ‘AWOL’ protocol was not applied appropriately I in a timely manner and during the course of the evidence it became apparent that some of the clinicians lacked familiarity with the protocol and process. Whilst the Trust has taken steps to ensure that the protocol has been discussed with the staff based on the ward in question, action has not been taken Trust wide to ensure that all staff are fully familiar with this police. Response: Following the Trust’s investigation, the Absence without Leave (AWOL) Policy was reviewed and additional guidance included in relation to actions that should be taken when a person goes AWOL. This policy was initially piloted within the Trust’s Mental Health In-Patient Unit at Tameside General Hospital. The revised policy was implemented Trust wide on the 1st April 2015. I have been assured by both In-Patient Service Manager for the North (Oldham/Rochdale/Bury) and the South (Stockport/Tameside) that this information has been shared and staff are familiar with the policy. In order to assist staff a flowchart has been produced as part of the policy, which also explains to staff when to contact the police to inform them of a patient who has not returned from leave (attached).
2. Clinical Psychology Service
— the only access afforded to a Clinical Psychologist depends upon three pre-requisites being met; I) discharge ii) to a fixed abode iii) onward referral by the Community Mental Health Team. There is no In-Patient Clinical Psychology facility and no ability for hospital clinicians
to refer a patient directly. This is a significant service gap and potentially prejudices/puts at risk some of the most vulnerable people, e.g. those who are no fixed abode. Response:
- There is access to Psychological Therapies on the ward, which takes the form of consultation, assessment and formulation and supervision for staff who are providing psychologically informed support to patients.
- A Consultant Psychiatrist or nursing staff can refer an in-patient for Psychological Therapies if appropriate.
- It is not necessary for a service user to have a home address in order to access Psychological Therapies whilst an in-patient, however once discharged they would have to have access to an address or a telephone in order to be contactable for future appointments.
- It is a requirement that secondary care patients accessing Psychological Therapies are open to a Care Coordinator, this is in order that individuals undergoing therapy may raise difficult and challenging issues, have a support network and crisis plan in place whilst doing exploratory therapy so that any increased risk can be managed. I hope this response assures you that the Trust takes seriously any concerns that you raised.
Sent To
- Pennine Care NHS Trust
Responses Identified
Responses identified
1 of 1
56-Day Deadline
7 Jan 2016
All listed responses identified
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 3rd November 2015, I commenced an investigation into the death of Guy Jeffrey Robinson.
Circumstances of the Death
Guy was a 31 year old man with enduring mental and physical health problems. He had been diagnosed as suffering from i) emotionally unstable personality disorder, ii) moderate depression, iii) post-traumatic stress disorder and iv) opiate dependence syndrome. The deceased had a tendency to self-harm and suffered periods of suicidal ideation, usually linked to life events and emotional instability. Furthermore, his physical health problems exacerbated his mental illnesses, increasing his anxiety levels. His ill-health resulted in frequent psychiatric inpatient episodes. Being ‘AWOL’ and absconding were not unusual for Guy, even when ‘under section’. On the 7th May 2014, Guy was admitted as an informal patient on the mental health unit. On the 21st June 2014 he was compulsorily detained under Section 5 (2); this was subsequently regraded to compulsory detention under S2 MHA on the 23rd June 2014. Guy was ‘under section’ at the time of his death. His Responsible Clinician had granted S.17 leave, which had been increased over time. On the evening of the 10th July 2014 Guy left the ward on S.17 leave but failed to return when expected. The ‘AWOL’ protocol was not put in place immediately, rather some 2.5 hours later, as staff took steps to search the hospital and grounds in accordance with what was said to be an agreed local protocol with police. The Police were called at around 21:13 on the 10th July and following extensive searches in accordance with the Force’s missing person protocols over the next few days, Guy was found deceased outdoors in undergrowth, on the evening of the 15th July 2014. A post mortem examination and toxicology were conducted. At inquest, a jury found the cause of death to be: 1a) Multiple drug toxicity
2) Exposure
2) Exposure
Copies Sent To
Pennine Acute Hospitals NHS Trust
NHS England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.