A coroner has raised concerns about the lack of coordination in mental health services for young people in Birmingham, after a patient under NHS care was found hanged.
Leah Abby Ratheram died on 7 October 2016 aged 20. She had Asperger’s syndrome and had previously been in the care of Birmingham and Solihull Mental Health Trust’s rapid assessment, interface and discharge team and was referred to Forward Thinking Birmingham.
Forward Thinking Birmingham, launched in 2015, is a mental health service for under-25s, provided by Birmingham Women’s and Children’s Foundation Trust, The Priory Group, Worcestershire Health and Care Trust, Beacon UK and the Children’s Society.
In a preventing future deaths report, published last month, Birmingham senior coroner Louise Hunt said there was a concern that patients being treated by the RAID team and Forward Thinking Birmingham will have “no coordination of care at a time of crisis”.
“It is also unclear who will ultimately be responsible for the patient particularly during their period of transfer,” she said.
Prior to her death, Ms Ratheram was referred to Birmingham and Solihull Mental Health Trust’s RAID team after presenting at University Hospitals Birmingham FT’s emergency department. Following an initial assessment, she was transferred to Forward Thinking Birmingham.
The coroner’s report said no formal handover had taken place between the RAID team and Forward Thinking Birmingham.
Ms Hunt warned that as both organisations use different record keeping systems “there is a real risk information will not be shared effectively and key risk factors will be missed in the handover process”.
The report highlighted the risk of not involving social care services at an early stage after a social care worker refused to be involved in Ms Ratheram’s care until her mental health assessment was completed.
It said: “There is a concern that the lack of involvement of this speciality at any early stage will affect the quality of mental health act assessments and the safety of patients.”
A copy of the report was sent to the Care Quality Commission.
A spokeswomen speaking on behalf of Birmingham and Solihull Mental Health Trust and Birmingham Women’s and Children’s Foundation Trust said:
“The death of Leah Ratheram in October 2016 was a tragic incident and we take the Coroner’s concerns extremely seriously. We are currently in the process of providing a formal response to the Coroner by the 10 May deadline, that will outline how we are working closely together, alongside our commissioners, to learn from this incident and further strengthen our existing pathways to mitigate risk in the future.
”This includes improving the process for handover of care between Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust. Our full response to the Coroner’s concerns will be available after 10 May.
”Our thoughts and condolences remain with Leah’s family and friends following their loss.”
15 March 2017