Roseanne Cooke
PFD Report
All Responded
Ref: 2014-0485
All 1 response received
· Deadline: 5 Jan 2015
Coroner's Concerns (AI summary)
Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.
View full coroner's concerns
_ It was clear from the evidence that the deceased required psychological input: The Inquest heard evidence that whilst she was an inpatient on the Grasmere Unit there was no inpatient psychological input available due to maternity leave which had not been covered. There_was confusion in the evidence as to whether_whilst an inpatient on time ,
Grasmere , a referral had been made to outpatient psychological services (.e the Recovery Team services) This resulted in a referral being made by her Care Co-ordinator on the 245 April when she had been already been discharged home_ This confusion meant that there was either a delay in any referral being made or at best a duplication of her referral. On the 17"h April there was a meeting which ultimately led to the discharge of the deceased from hospital. The Care Co-Coordinator had already expressed that she would not be available due to annual leave but had left details of her colleague who would attend if this was a discharge planning meeting: No-one from the Recovery Team attended this meeting: were the prime carers for the deceased on her discharge and had the role of Care Co-ordinator. On the 28"h April; the deceased's family contacted the Home Treatment out of hours numbers available to them as they had concerns about the deceased being in the house on her own the following day as she was having suicidal thoughts. Their understanding of the request was that someone from the Recovery Team would visit her the following day: The message passed to the Recovery Team was simply to make contact with the deceased, which was done over the phone: The extent of the concerns raised by the family was not communicated to the Recovery Team.
Grasmere , a referral had been made to outpatient psychological services (.e the Recovery Team services) This resulted in a referral being made by her Care Co-ordinator on the 245 April when she had been already been discharged home_ This confusion meant that there was either a delay in any referral being made or at best a duplication of her referral. On the 17"h April there was a meeting which ultimately led to the discharge of the deceased from hospital. The Care Co-Coordinator had already expressed that she would not be available due to annual leave but had left details of her colleague who would attend if this was a discharge planning meeting: No-one from the Recovery Team attended this meeting: were the prime carers for the deceased on her discharge and had the role of Care Co-ordinator. On the 28"h April; the deceased's family contacted the Home Treatment out of hours numbers available to them as they had concerns about the deceased being in the house on her own the following day as she was having suicidal thoughts. Their understanding of the request was that someone from the Recovery Team would visit her the following day: The message passed to the Recovery Team was simply to make contact with the deceased, which was done over the phone: The extent of the concerns raised by the family was not communicated to the Recovery Team.
Responses
Action Taken
The Trust has looked into the concerns raised and has put an action plan in place after a period of no psychological input on the Grasmere Unit due to maternity leave, despite a patient's need. Actions include: All referrals to be written on specific form and recorded on electronic system, the manager to ensure annual leave handover forms are discussed within team meetings, and operation of an electronic patient record. (AI summary)
The Trust has looked into the concerns raised and has put an action plan in place after a period of no psychological input on the Grasmere Unit due to maternity leave, despite a patient's need. Actions include: All referrals to be written on specific form and recorded on electronic system, the manager to ensure annual leave handover forms are discussed within team meetings, and operation of an electronic patient record. (AI summary)
View full response
Dear Miss Kearsley Re: Mrs Roseanne Cooke (Deceased) Thank you for letter dated 10 November 2014 with regards to your findings into the death of Mrs Rosanne Cooke and the directions given under Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. The Trust takes the matters described within the letter extremely seriously and hopes this response addresses the concerns you have raised. In addition have demonstrated to your satisfaction the learning within the Trust as a result of your correspondence Taking points inturn can confirm the following actions have been undertaken by the Trust: Psychological Input - Grasmere Unit Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trultt Headquarters, Hollins Park House; Hollins Lane Winwick, Warrington; WAZ 8WA Mini Com Number 01925 664094 Trust hope your
The Trust has looked into the concerns you have raised regarding psychological input whilst Mrs Cooke was patient on Grasmere Unit and the following has been established_ The Grasmere Unit Psychologist was on maternity leave, from 1 October 2013 _ 1 September 2014. Mrs Cooke was admitted on 7 March 2014. Psychology cover was Provided during the period of maternity leave by the Psychological Therapy staff Knowsley Recovery Team who attended ward rounds and provided psychological assessmentlinterventions a8 requested by Grasmere Unit: Unfortunately there is no record of Grasmere Unit staff referring Mrs Cooke, despite the identified need for psychological input: An action plan has been produced and is attached for your information. However ! have taken the opportunity to summarise actions below. The Trust operates a process for services to plan for extended such as maternity leave, however recognise, in this instance, this did not work as well as it should would like to assure you that additional steps will be added to the process to ensure actions and those responsible are more formally identified. These steps are detailed within the attached action plan, along with action owners and dates for completion, and include: Support from the Professional Lead for Psychology, who will review Psychology provision across the Trust and advise as to the options available for Cross cover Psychology arrangements_ Production of an extended leave plan that will have clear deadlines and ensure alternatives are identified at least four weeks prior to commencement of the planned leave. The Business Manager will ensure Grasmere Unit staff are instructed to provide more detailed entries into the electronic record system relating to psychological input discussions This will include their immediate action(s) in relation to the patient_ The Leadership Team for Grasmere Unit will commission an audit of the psychology referral documentation to ensure it identifies the type, level and urgency of referral: II. Referral Process for Psychological Services Ris evidentthat a delay occurred in processing Mrs Cooke's referral to Warrington Recovery Team's Psychology Service. would like to offer my unreserved apologies to the family of Mrs Cooke for this delay which was a result of the Care Co-ordinator Failing to submit a referral to Warrington Psychological Therapies (Warrington Recovery Team) in a timely manner. Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane; Winwick, Warrington; WAZ 8WA Mini Com Number 01925 664094 from the leave KBou, i5A
In response to this the Borough's Leadership Team has implemented a plan to identify reasons for this failure via an audit of internal referrals to Psychological Therapies by Warrington Recovery Team: Findings from the audit will be developed into recommendations for improving the referral process The failure to refer in a timely manner will be addressed with the Care Co-ordinator via Trust Management process and Clinical Supervision. III: Discharge Planning Meetings The Trust operates a standard in relation to Discharge Planning which reflects the Programme Approach (CPA) principles. This includes a requirement for practitioners to ensure safe , effective transition for patients would like to take this opportunity to advise you of Trust activity to implement use of the Safer_Mental Health Checklist; developed by the National Patient Safety Agency (NPSA) This checklist ensures that the activity in relation to a patients transfer from one team to another is planned and monitored. The checklist also includes a review of the Risk Management Plan prior to any change in service and a review of CPA status between transfer and receiving teams_ It is evident that Warrington Recovery Team (as the receiving team) failed to send any representation to the Multi-Disciplinary Team MDT meeting and this is an oversight on our part: In order to address the Warrington Recovery Team Manager will ensure annual leave handover forms are completed These will detail actions pertaining to individual service users, and also which staff member within the Team will ensure these are completed in the absence of the Care Co-ordinator. These forms will be referenced at existing weekly Recovery Team meetings. The manager will ensure annual leave handover forms are discussed within the Team Meeting prior to any planned leave_ This action will address the potential of such an oversight recurring and will also ensure that actions are known by all team members and recorded IV. Communication between Teams The Trust operates an electronic patient record which ensures that activity in one team can be accessed by other Trust teams supporting the same patient Information relating to contact from Mrs Cooke's family was recorded and detailed concerns and request for a home visit to his wife for the next Having reviewed Mrs Cooke's electronic record the following the Care Co-ordinator contacted Mrs Cooke to discuss During this contact; Mrs Cooke Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane Winwick; Warrington; WAZ 8WA Mini Com Number 01925 664094 8 Meetings Care delivery this, day. day, 480uf Disabl
described feeling much better, and was out at the time of the call, dealing with banking affairs and it was agreed to to the scheduled appointment for the next day: The Care Co-ordinator was assured by her conversation with Mrs Cooke and advised that should Mrs Cooke's feelings change in any way, then she was to make contact with her Care Co-ordinator. In conclusion would again like to offer my apologies to the family of Mrs Cooke for the failings identified. trust this letter and attached action plan addresses the concerns raised. If ! can be of any further assistance or You require further information about the steps we have taken please do not hesitate to contact me_
The Trust has looked into the concerns you have raised regarding psychological input whilst Mrs Cooke was patient on Grasmere Unit and the following has been established_ The Grasmere Unit Psychologist was on maternity leave, from 1 October 2013 _ 1 September 2014. Mrs Cooke was admitted on 7 March 2014. Psychology cover was Provided during the period of maternity leave by the Psychological Therapy staff Knowsley Recovery Team who attended ward rounds and provided psychological assessmentlinterventions a8 requested by Grasmere Unit: Unfortunately there is no record of Grasmere Unit staff referring Mrs Cooke, despite the identified need for psychological input: An action plan has been produced and is attached for your information. However ! have taken the opportunity to summarise actions below. The Trust operates a process for services to plan for extended such as maternity leave, however recognise, in this instance, this did not work as well as it should would like to assure you that additional steps will be added to the process to ensure actions and those responsible are more formally identified. These steps are detailed within the attached action plan, along with action owners and dates for completion, and include: Support from the Professional Lead for Psychology, who will review Psychology provision across the Trust and advise as to the options available for Cross cover Psychology arrangements_ Production of an extended leave plan that will have clear deadlines and ensure alternatives are identified at least four weeks prior to commencement of the planned leave. The Business Manager will ensure Grasmere Unit staff are instructed to provide more detailed entries into the electronic record system relating to psychological input discussions This will include their immediate action(s) in relation to the patient_ The Leadership Team for Grasmere Unit will commission an audit of the psychology referral documentation to ensure it identifies the type, level and urgency of referral: II. Referral Process for Psychological Services Ris evidentthat a delay occurred in processing Mrs Cooke's referral to Warrington Recovery Team's Psychology Service. would like to offer my unreserved apologies to the family of Mrs Cooke for this delay which was a result of the Care Co-ordinator Failing to submit a referral to Warrington Psychological Therapies (Warrington Recovery Team) in a timely manner. Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane; Winwick, Warrington; WAZ 8WA Mini Com Number 01925 664094 from the leave KBou, i5A
In response to this the Borough's Leadership Team has implemented a plan to identify reasons for this failure via an audit of internal referrals to Psychological Therapies by Warrington Recovery Team: Findings from the audit will be developed into recommendations for improving the referral process The failure to refer in a timely manner will be addressed with the Care Co-ordinator via Trust Management process and Clinical Supervision. III: Discharge Planning Meetings The Trust operates a standard in relation to Discharge Planning which reflects the Programme Approach (CPA) principles. This includes a requirement for practitioners to ensure safe , effective transition for patients would like to take this opportunity to advise you of Trust activity to implement use of the Safer_Mental Health Checklist; developed by the National Patient Safety Agency (NPSA) This checklist ensures that the activity in relation to a patients transfer from one team to another is planned and monitored. The checklist also includes a review of the Risk Management Plan prior to any change in service and a review of CPA status between transfer and receiving teams_ It is evident that Warrington Recovery Team (as the receiving team) failed to send any representation to the Multi-Disciplinary Team MDT meeting and this is an oversight on our part: In order to address the Warrington Recovery Team Manager will ensure annual leave handover forms are completed These will detail actions pertaining to individual service users, and also which staff member within the Team will ensure these are completed in the absence of the Care Co-ordinator. These forms will be referenced at existing weekly Recovery Team meetings. The manager will ensure annual leave handover forms are discussed within the Team Meeting prior to any planned leave_ This action will address the potential of such an oversight recurring and will also ensure that actions are known by all team members and recorded IV. Communication between Teams The Trust operates an electronic patient record which ensures that activity in one team can be accessed by other Trust teams supporting the same patient Information relating to contact from Mrs Cooke's family was recorded and detailed concerns and request for a home visit to his wife for the next Having reviewed Mrs Cooke's electronic record the following the Care Co-ordinator contacted Mrs Cooke to discuss During this contact; Mrs Cooke Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane Winwick; Warrington; WAZ 8WA Mini Com Number 01925 664094 8 Meetings Care delivery this, day. day, 480uf Disabl
described feeling much better, and was out at the time of the call, dealing with banking affairs and it was agreed to to the scheduled appointment for the next day: The Care Co-ordinator was assured by her conversation with Mrs Cooke and advised that should Mrs Cooke's feelings change in any way, then she was to make contact with her Care Co-ordinator. In conclusion would again like to offer my apologies to the family of Mrs Cooke for the failings identified. trust this letter and attached action plan addresses the concerns raised. If ! can be of any further assistance or You require further information about the steps we have taken please do not hesitate to contact me_
Sent To
- 5 Boroughs Partnership NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
5 Jan 2015
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 6 May 2014 | commenced an investigation into the death of Roseanne Cooke date of birth 20.05.1958. The investigation concluded on the 27th October and the conclusion was one that the deceased had taken her own life. The medical cause of death was recorded as Ia) Hanging
Circumstances of the Death
Fheard evidence that the deceased had, over a relatively short period of had a marked deterioration in her mental health ~ a prominent feature of which was suicidal thoughts. She had been an inpatient on the Sheridan Ward in January 2014 until her discharge on the 7th February 2014. On the 26" February she then re-presented having taken an overdose and was then transferred to the Grasemere Unit at Whiston Hospital due to a shortage of beds She remained an inpatient and was transferred back to the Sheridan Ward on the 9th April, A week later on the 17/h April 2014 she was discharged home under the care of the Home Treatment and Recovery Teams: On the 1st May 2014 the deceased was found having taken her own life at her Mother's home
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:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.