Rose Chambers: Trust should take action to prevent further deaths, says coroner
An NHS trust has been told to make changes to its services to prevent future deaths following an inquest into the death of a Shrewsbury teenager who took her own life.
The inquest heard various concerns from the family regarding her care, and how she told mental health nurses of her intention to kill herself on April 30, or the following day.
Mr Ellery sent a regulation 28 report to the Midlands Partnership Foundation Trust on Friday, in which he said action should be taken by the trust to prevent future deaths.
In his report sent to trust chief executive Neil Carr, he said two specific issues arose which could not be said to have caused or contributed to Miss Chambers' death but could in others.
He raised concerns about Miss Chambers being on the waiting list for counselling at the time of her death.
Mr Ellery said: "The evidence at the inquest was that a three-month time interval would be optimal but in Rose’s case, in relation to this GP surgery, 10 months would be the norm.
"Such a delay is sub-optimal and could have an adverse effect on a patient waiting for counselling to commence."
Need help?
Help and advice for those having a mental health crisis is available from a number of agencies in Shropshire.
Shropshire Mind - 01743 368647 or shropshiremind.org
Samaritans - 116 123 or samaritans.org
Access Service for Adult Mental Health - 03001 240365
Every Mind Matters - nhs.uk/oneyou/every-mind-matters
Other concerns raised by the family, and highlighted in the coroner's report were around risk assessment and progress notes.
Mr Ellery explained that electronic notes were hard to follow or understand, particularly when said to have been updated or validated with the potential for original entries to have been overwritten.
He also said it was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes.
Concluding his report, Mr Ellery added: "In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.
"You are under a duty to respond to this report within 56 days of the date of this report, namely by February 15, 2019. 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.”
