Mental healthcare specialists missed five opportunities to complete suicide risk assessments on an 18-year-old girl in the three months before she was fatally hit by a train, an inquest heard today.
Oh, goodness! Must be those ‘lack of resources’ we’re always hearing about from the ‘cash-starved NHS’, right?
The Croydon teenager had been diagnosed with bipolar disorder shortly after the death of her father from cancer in her early teens and had tried to commit suicide three times between 2012 and 2014.
The day she died she had been helping another friend whose father had died.
When she was transferred from Croydon CAMS (children mental health services) to adult mental health services in June last year, no formal risk assessment or care plan was completed.
The meeting was not even recorded and there is no written documentation with details of what took place.
Speaking at the inquest at Westminster Coroners’ Court today, clinical nurse specialist Katherine Delvin of Croydon CAMS, who was present at the 30-minute handover meeting said: “On reflection I wish I had updated the risk assessment.”
The nurse had sent a letter to the adult mental health team detailing two of Miss Romero’s previous suicide attempts, diagnosis and history of self harm.
But no formal risk assessment had been completed since she was discharged from Springfield Hospital in Tooting in February of that year.
Her new care co-ordinator at South London and Maudsley NHS Mental Health Trust Pauline Laforge, formerly a psychiatric nurse with 32 years experience in mental health, then failed to complete the risk assessment and care plan at four further meetings.
The care plan would have included a strategy of how to deal with crisis situations and a telephone contact for a mental health specialist she could have called, the court heard.
Hmmm, I guess not.
I mean, they clearly had time and resources to make the appointments, just couldn’t be bothered with all that yucky paperwork that those meanies at NHS high command insist on. Such a drag, when there’s ‘Heat’ magazine to read, and Brenda in Reception wants to tell you what happened on GBBO last night…
And it’s not unusual:
An audit of patient records carried out following Miss Romero’s death found that only between 30 and 40 per cent of adult mental health patients in Croydon had care plans completed.
Some might say that it’s not how many resources you have, it’s how they are employed that counts. But they clearly don’t work in the NHS:
Ms Laforge told the court the care plan and risk assessment had not been completed due to her “high” case load of 33 patients.
33 patients? Is that all? A day? A year? What?