Missed Opportunities & Lessons Learned

How many times do we have to keep hearing these two phrases after Investigations and Inquests?  I received a copy of the Regulation 28 issued by the Coroner (recommendations to prevent further deaths) after Jake’s inquest Dec 2015.   The Regulation 28 was sent to 3 organisations, 1) The Chief Executive Greater Manchester West Mental Health Team, 2) The Medical Director of the Greater Manchester NHS Area Team and 3) The Practice Manager at a Health Centre which I will not name.  I was absolutely stunned to read in the Coroners Report, ‘This has happened before and lessons have not been learned’. I felt sick.  I studied very carefully, each of the 3 responses, I asked further questions and sought clarification.  What I found, I will include in future Blogs under various headings.  In my quest to find out what this comment (above) was referring to, I wrote to the Medical Director of NHS England (the organisation who this comment was directed at) and I asked the question “Why did the Coroner feel the need to include this in Jake’s Regulation 28?” The Medical Director of GM NHS Area Team wrote to me inviting me to meet with him.  I have to say that he was extremely generous with his time and I found him to be sincere.  He talked me through his responses and I felt re-assured that a thorough job had been done of responding to the Coroners findings and recommendations. He made the following recommendations:-

1. A Dual Diagnosis Steering Group has been set up as a result of Jake’s death.
2. Services that offer different services, but work together (shared care) need to improve their relationships and communication to avoid ambiguity (structured Management needed)
3. The Community Mental Health Team (who had assessed Jake over the phone as high risk) have since Jake’s death been advised to attend jointly appointments with other organisations to improve engagement and assessment for Jake.  Such simple changes could make a huge difference to the lives of other.  It also in my opinion could save the NHS money. The Coroners words were ‘be more imaginative’. Jake never actually got to meet with the CMHT.  In fact I phoned them on Monday 24/08/15 to say that he was dead and would not be needing the appointment on Fri 28/08/15.
4. A letter was sent to all GP’s outlining best practice when sending urgent correspondence. This is a contractual obligation which will be monitored by the Commissioner.
5. Guidance on suicide prevention i.e. the need to always note the risk, irrespective of any previous understanding by the recipient (basically, don’t assume that other know the risk, always make it clear)
6. Review policies and procedures for vulnerable patients who miss appointments
7. To undertake a review of systems in place to track and to establish the lessons learned from any incidents and near misses.

Now back to  ‘This has happened before and lessons have not been learned’.   I asked Dr R. Patel a direct question “was this comment referring to an organisation (who I will not name) where a letter went missing?”  Dr. R. Patel was able to answer without breaking any confidentiality.  The comment was referring to the case of a vulnerable individual who moved address several times and the issue was with systems that are not joined up/updated.  I was able to stop being haunted by my own workings out in my head and was assured that this issue had been addressed and had no direct influence on Jake’s death.

As I continue to blog, one of the key things that am determined to do is to follow up point 7. (above) To undertake a review of systems in place to track and to establish the lessons learned from any incidents and near misses.  Regulation 28’s must not be dealt with in isolation for individuals.  They must be cross-referenced, monitored and audited.  Jake did well for a 23 year old young man to share everything with me his mother and without this insight Jake’s case would have been an open and shut case and there would not have been a Regulation 28 changes would not come about.

Dr R. Patel told me that after Jake’s Inquest the Coroner requested a meeting with him to discuss cases across GMW and she said to him “Your systems are baffling”  They are indeed……

#suicide prevention  #after suicide blog