Clinical & Medical Negligence Newsletter - Attwaters Jameson Hill - Spring 2018

Spring 2018 Medical Negligence Newsletter | 07 „ „ Recommendations made by consultant psychiatrists following incidents in April concerning her admission or the involvement of the Crisis Resolution and Home Treatment Teamwere not followed „ „ An incident in late May should have led to a comprehensive risk assessment review, but this did not take place; it was therefore inappropriate to discharge Katherine on 1 June „ „ Katherine’s support network was not informed of her discharge and should have been alerted „ „ The involvement of Social Services was not actively pursued to help Katherine manage her anxieties „ „ There was a failure to undertake an assessment as required under the Mental Health Act following an incident on 29 May; on the balance of probability, this significantly contributed to Katherine’s death. The jury concluded that a review of all the evidence supported the view that Katherine did not have an effective advocate for her needs. Medical Negligence Solicitor Craig Knightley who led the teamworking on this tragic case commented: “The Coroner’s Court heard a catalogue of errors and rightly concluded that Katherine had not received the care and support she so desperately needed. The issues that came to light were all the more concerning in the light of Norfolk and Suffolk NHS Foundation Trust being placed in special measures last year, due to the failure of its Board to address serious concerns expressed in a 2014 Care Quality Commission report that rated it ‘inadequate’. It seems that lessons have not been learned, and issues surrounding the care of some of the most vulnerable patients have yet to be addressed” . “ The family also had concerns that electroconvulsive therapy (ECT) hadn’t been deployed appropriately”