Tommy Faisali
PFD Report
Historic (No Identified Response)
Coroner's Concerns (AI summary)
Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.
View full coroner's concerns
In the circumstances it is my statutory to report to you: _ That patients referred by their GP for second opinion from psychiatrists are not being seen by the same but rather by psychiatric health care staff with less qualification to diagnose and assess and recommend treatment then the GP who made the referral.
(2) That a shortage of appropriately qualified doctors is being compensated for by staff withoul the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals_ (3) Those patients may be at increased risk because of (1) and (2) above (4) That staff within the mental health teams are not completing risk assessments or at least not appropriately documenting that they are.
(5) That risks to patients, including risk of suicide is thus not appropriately communicated to other team members, thereby increasing the risks to those patients_ (6) That risks arising from (5) are even more increased given the team approach to care and lack of continuity of care inherent in such ways of working:
(2) That a shortage of appropriately qualified doctors is being compensated for by staff withoul the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals_ (3) Those patients may be at increased risk because of (1) and (2) above (4) That staff within the mental health teams are not completing risk assessments or at least not appropriately documenting that they are.
(5) That risks to patients, including risk of suicide is thus not appropriately communicated to other team members, thereby increasing the risks to those patients_ (6) That risks arising from (5) are even more increased given the team approach to care and lack of continuity of care inherent in such ways of working:
Sent To
- Central and North West London NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
2 Sep 2015
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 3oth October 2014 ! commenced an investigation into the death of Mr Tommy Faegh Faisali aged 54 years_ The investigation concluded at the end of the inquest on Tuesday gth June 2015. The conclusion of the inquest was: Medical Cause of Death (a) Acute pulmonary oedema (b) Methodone toxicity (c) Liver failure due to cirrhosi How; when and where the deceased came by his death: Mr Faisali suffered with hepatitis C which caused cirrhosis. He was also methodone dependent: On 30/9/2014 he was found deceased within his accommodation. There were no suspicious circumstances and no evidence that he intended to take his own life. The cirrhosis impaired his ability to metabolise the methodone Conclusion of the as to the death Drug related misadventure_
Circumstances of the Death
It was clear from the evidence taken during the inquest that despite four separate referrals by his GP to psychiatrists over the years, he had never been seen and assessed by one, such that he never received the benefit of specialist psychiatric input into the_management of his complex psychiatric and psychological issues_He was only Jury ever seen by CPNs or health care assistants or similar from the psychiatric services, none of whom where qualified to diagnose nor direct treatment: During the taking of the evidence it became clear that there was no evidence of documented risk assessment, including suicide risk assessment performed by the last mental health team providing care to him: His assessment by that team was also not recorded on his psychiatric notes in any contemporaneous way: All that could be found was a letter sent back to the GP after he was seen.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action:
Copies Sent To
David Behan Chief Executive
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.