Coroner to warn mental health trust over staff not reading patients' notes
A coroner has warned the region's mental health trust was making the same mistake repeatedly after a teenager's mental health records were not looked at before he was seen.
Senior coroner for Norfolk Jacqueline Lake made the warning at the conclusion of the inquest into the death of Cromer teenager Nyall Brown.
Mr Brown, 19, died on May 22 last year, and the medical cause of death was given as hanging.
An inquest on Thursday heard how “funny” and “mischievous” Mr Brown had struggled with his mental health for a number of months.
In January he had attempted suicide but had alerted police to where he was and ended up in intensive care, but survived.
The inquest heard how Mr Brown was seen by Norfolk and Suffolk Foundation Trust’s (NSFT) crisis resolution and home treatment team (CRHT) but the decision was made that he would see the Wellbeing team instead.
However when Darrell Yaxley, a psychological wellbeing worker with the Wellbeing Service, did see Mr Brown he had not read his notes beforehand so was not aware of his full history.
Mrs Lake gave a short narrative conclusion at the end of the inquest. She ruled out a conclusion of suicide as she said she could not be assured Mr Brown meant to take his own life.
She said: “Nyall was clearly down and distressed and was not engaging [with services]. He had sent a text to his parents to say he could not go on and he was sorry. Immediately after sending that text he send a second text indicating where he was.
“I have to take into account he may have been expecting to be found as he had on the previous occasion.”
After Mr Brown’s death NSFT carried out a serious incident investigation and on Thursday Michael Cummings, service manager for CRHT, outlined 11 recommendations for changes to be made.
Mrs Lake said she was satisfied NSFT had taken action on concerns over risk assessments.
She said: “However I do have continuing concern that not as much information is being obtained prior to a service user being seen by practitioners. I do have concern that the records were not read, that concern has been raised by me before.”
When asked Mr Cummings said the records should be read, and during his evidence said it was “not acceptable” if they were not read.
And Mrs Lake said she was also concerned this had not been included in what was otherwise a “thorough investigation”.
She said she would be writing a regulation 28 report, which calls on NSFT to make improvements to prevent further deaths.
Diane Hull, chief nurse at NSFT, said: “We would like to express our most sincere condolences to the family of Nyall Brown following his devastating death in May last year.
“We are grateful to the coroner for issuing a prevention of future deaths report which will help to ensure that each member of our staff coming into contact with a service user for the first time will review their records in order to have a full history of the care we have already provided.
“Our trust carried out a detailed review of the events leading up to Nyall’s death and we are now concentrating on fully implementing the learning from our review.
“Much of this work focuses on strengthening the supervision, systems and processes in our Wellbeing service to ensure it works in a more integrated way with secondary mental health services.
“Again, we would like to pass on our most sincere condolences to Nyall’s family and also to thank Mr and Mrs Brown for the very positive contribution they made to the review.
“We are in the process of implementing their recommendations to appoint a family liaison officer to support families in serious incident cases and will hold a learning event for staff involved in their son’s care to ensure that improvements are embedded into practice. We have already started the recruitment process for the family liaison officer post which will be filled very soon.”