Lorna Cullen

PFD Report Historic (No Identified Response) Ref: 2014-0105
Date of Report 11 March 2014
Coroner Allison Summers
Coroner Area Mid Kent & Medway
Response Deadline est. 6 May 2014
Coroner's Concerns (AI summary)
The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health assessments were regularly waiting in excess of 2 hours due to staffing shortages.
View full coroner's concerns
It became apparent that if the deceased had waited at the hospital she would not in fact have been seen until at least midnight and possibly later (more than twice the standard time): The reason for this was due to the fact that there was only one nurse on duty during the 'late' shift and in view of the fact that a mental health assessment takes between 2-3 hours the demand (the nurse on duty receives referrals a number of different departments within the hospital) far exceeded the available staffing provision. It was apparent from the evidence of at least three witnesses that at the time of this death in 2012, patients in need of mental health assessment by the on-duty Iiaison psychiatry nurse were regularly waiting well in excess of 2 hours_ The importance of a mental health assessment taking place as soon as possible after such a need has been identified is obvious specially trained psychiatry nurse is more likely to pick up on the more subtle indicators as to risk, that means it is more likely that appropriate management of that risk can be put into place thus affording the most effective preventive measures against self-harm and harm to others_ 23rd history 17th 22nd the triage hour from

During the course of the inquest heard evidence that as a result of review additional resources had been awarded to facilitate increased staffing levels and to provide a 24 hour service (previously there were no liaison nurses on duty after midnight) thus providing continuation of services before and after midnight: was advised that the additional levels of funding remain in place until at least the end of September 2014. The effect of these resources has been to significantly decrease the number of patients who require mental health assessments and who have to wait in excess of 2 hours. It has meant that staff can properly research a patient's prior to or as part of the assessment which is not only essential so far as assessing the individual patient but is useful in assessing priority as between patients waiting to be seen. The matter of concern therefore relates to the long term (ie post September 2014) Iiaison psychiatry nurse staffing levels covering hospital emergency departments_
Sent To
  • NHS Medway Clinical Commissioning Group
  • NHS Swale Clinical Commissioning Group
Response Status
Linked responses 0 of 2
56-Day Deadline 6 May 2014
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 2nd January 2013 an investigation into the death of Lorna Frances Cullen was commenced_ The investigation concluded at the end of the inquest on the 26th February 2014. returned a short narrative conclusion_ Fifty
Circumstances of the Death
In the early hours of the morning of Sunday December 2012, Lorna Cullen was seen falling from the upper level of a multi-story car park. She suffered multiple injuries and died. No other person was involved in the event: There was long of mental health problems and at the time of her death she was under the care of the mental health services. Between the and 21st December 2012 there was noticeable deterioration in her mental health. She referred to "living forever" and on the afternoon of the 22nd December 2012 she referred to herself as being "an action man"_ During early evening of the December 2012 Lorna Cullen attended at the Emergency Department of Medway Maritime Hospital. She was assessed within 20 minutes of her arrival at the hospital: She was assessed as requiring a mental health assessment. She was noted to be "threatening suicide" . She was not assessed as 'high risk, meaning that she did not need immediate assessment and treatment but was expected to be assessed within the standard 2 period from the time of the referral to the Iiaison psychiatry nurse on duty. Less than twenty minutes later and before any assessment had been carried out, Lorna Cullen left the hospital. The next time she was seen was when she was captured on closed circuit television falling from the car park.
Action Should Be Taken
recommend that action be taken to ensure that the following resources are available on permanent basis (subject to any significant changes in demand due to for example a change in the arrangement of services): The current liaison psychiatry nurse staffing levels. This means ensuring that there are at least two members of staff available during the and late shifts_ The operation of a 24 hour liaison psychiatry service
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.