Lee Swain

and an assessment never took place. Within the Mental Health Services, the following failures occurred in the care and treatment of Lee: Mersey Care inappropriately removed him from the CPA when he clearly needed the continuity and engagement; Lee’s care was not co-ordinated across services. Referrals through the GP were made rather than a transfer from service to service. If Lee had remained under the CPA the transfer would have been more effective – service to service; Despite Knowing that Lee was moving to the Wirral in March 2016 a referral letter with the clinical history was not sent until June 2016 which was an unacceptable delay; Cheshire Wirral Partnership Mental Health Services’ Staff failed to adhere to Operational procedures in that the clinical notes were poor and inadequate. The notes were brief and did not fully detail decisions made or rationale for those decisions; CWP engagement with Lee fell short of expected standards, essentially comprising of appointment letters to his home address. The pattern of non-attendance should have triggered a more pro-active response to engage Lee with the service. There were a number of failures by the mental health services. It is unclear as to whether a more effective transfer from one service to another and thus earlier and more pro-active intervention would have changed the outcome for Lee, however, there were clear missed opportunities for further intervention to help and support Lee. A more co-ordinated approach from the mental health services may have given better opportunities to engage Lee so that he could have received the support and treatment he so desperately needed. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – A more co-ordinated approach from the mental health services is required when a user is being transferred from one NHS Trust to another. In this case if the user had still been on a Care Programme Approach there would have been a direct referral from service to service rather than through the GP but because he was taken off the programme the referral was made through the GP. This has delayed the intervention and the prevented effective information exchange on a user who was already subject to secondary care services. In effect this resulted in the user having no intervention for a number of months and entering the mental health system afresh when in fact the care should have been a seamless continuation. The Court would like you the Current Transfer / Referral Policy. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14/08/2017. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.