Andrew Frost
PFD Report
All Responded
Ref: 2015-0119
All 1 response received
· Deadline: 9 Apr 2015
Coroner's Concerns (AI summary)
A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for specific training on crisis team service limitations.
View full coroner's concerns
During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone.
You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him.
However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do.
You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.
You regarded the crisis team as an emergency service, which the team leader told me in court is not the case.
It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations.
I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else.
You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him.
However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do.
You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.
You regarded the crisis team as an emergency service, which the team leader told me in court is not the case.
It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations.
I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else.
Responses
Action Planned
The health centre met with the Crisis Team to discuss service provision and will hold meetings every 6 months to discuss the Crisis Team service and individual clients. (AI summary)
The health centre met with the Crisis Team to discuss service provision and will hold meetings every 6 months to discuss the Crisis Team service and individual clients. (AI summary)
View full response
(ox Killick Street Health Centre 75 Killick Street; London N1 9RH 020 7833 9939 020 7427 2740
Miss Mary Hassle St Pancras Coroner' s Office and Court Camley Street London NIC 4PP Tel: 020 7974 4545 Fax: 020 7383 2485 Following your requirement for our service to meet with the Crisis Team, can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. met up with both senior Managers at the Crisis team: Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP's at the practice and also to enable us to discuss individual clients_ We fully understand how the crisis service works. are an urgent care service that has a requirement to meet a client within 24 hours of referral. However, if someone is too unwell to await this amount of time then the step is to call the Police or the Ambulance service_ We are meeting as a clinical service with the Crisis team on the 11" of May at 1.3Opm for a meeting to discuss service and clients_ We hope to maintain this every 6 months minimum_ The Crisis team will be doing their own report to you but can state that they already invite all GP's to meet with them on the regular basis and have a relatively low take up on this. They will continue to send invites out; it is up to individual practices whether meet with them or not: We have agreed to meet with the Crisis team on the regular basis hope this letter fulfils the requirements set out in your report dated 12" February 2015. If you require any further information please do not hesitate to contact me: Many thanks.
Miss Mary Hassle St Pancras Coroner' s Office and Court Camley Street London NIC 4PP Tel: 020 7974 4545 Fax: 020 7383 2485 Following your requirement for our service to meet with the Crisis Team, can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. met up with both senior Managers at the Crisis team: Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP's at the practice and also to enable us to discuss individual clients_ We fully understand how the crisis service works. are an urgent care service that has a requirement to meet a client within 24 hours of referral. However, if someone is too unwell to await this amount of time then the step is to call the Police or the Ambulance service_ We are meeting as a clinical service with the Crisis team on the 11" of May at 1.3Opm for a meeting to discuss service and clients_ We hope to maintain this every 6 months minimum_ The Crisis team will be doing their own report to you but can state that they already invite all GP's to meet with them on the regular basis and have a relatively low take up on this. They will continue to send invites out; it is up to individual practices whether meet with them or not: We have agreed to meet with the Crisis team on the regular basis hope this letter fulfils the requirements set out in your report dated 12" February 2015. If you require any further information please do not hesitate to contact me: Many thanks.
Sent To
- Killick Street Health Centre
Response Status
Linked responses
1 of 1
56-Day Deadline
9 Apr 2015
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 30 September 2014, I commenced an investigation into the death of Andrew Elliot Frost, aged 34 years. The investigation concluded at the end of the inquest yesterday.
I made a determination that Andrew Frost took his own life.
I made a determination that Andrew Frost took his own life.
Circumstances of the Death
Mr Frost jumped in front of an underground train early in the morning on 25 September 2014.
The day before his death, he had three separate encounters with the authorities, the first with police; the second with police, paramedics, general practitioner and crisis team; the third with police and paramedics. On each occasion, concern was shown for Mr Frost and attempts were made to assist him.
The day before his death, he had three separate encounters with the authorities, the first with police; the second with police, paramedics, general practitioner and crisis team; the third with police and paramedics. On each occasion, concern was shown for Mr Frost and attempts were made to assist him.
Copies Sent To
Care Quality Commission for England
Professor Dame Sally Davies, Chief Medical Officer for England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.