Re Mary Gwanyama (PFD report sent to Surrey and Borders Partnership)  MHLO 1
PFD report The matters of concern in this Preventing Future Deaths report included: (1) there was no policy to prevent a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit (Mary had been discharged without a discharge planning meeting and with no housing plan beyond 7 days in a Travel Lodge); (2) there was no policy mandating when or if a patient should be subject to face-to-face review by a consultant psychiatrist after discharge (Mary was not subject to a medical review between discharge on 28/3/18 and suicide on 26/5/18); (3) no formal risk assessment was undertaken, and no risk assessment was recorded; (4) informal risk assessments arrived at an incorrect assessment of risk having ignored the impact of discharge with an inchoate housing plan; (5) in part because the imperative to discharge took precedence over discharge planning and assessment, Mary was discharged prematurely with severe depression before sufficient time had been taken to observe the effectiveness of her prescribed medication, in breach of the CPA; (6) Mary was discharged on ineffective medication, without any coherent care plan, without her care coordinator being involved, in breach of the CPA; (7) there was no policy governing how often a patient should be seen in the community to review the risk assessment and monitor medication compliance (Mary was placed out of area which made community treatment and support difficult, and was not seen by her care co-ordinator in the 35 days before she died).
Metadata from Judiciary website
23 April 2021 - Prevention of Future Deaths - Community health care and emergency services related deaths - Hospital Death (Clinical Procedures and medical management) related deaths - Mental Health related deaths - Railway related deaths - Suicide (from 2015) - PFD Report - Coroner
Date of report: 21 April 2021
Deceased name: Mary Gwanyama
Coroner name: Caroline Topping
Coroner Area: Surrey
Category: Hospital Death (Clinical Procedures and medical management) related deaths - Mental Health related deaths - Community health care - Railway related deaths - Suicide (from 2015)
This report is being sent to: Surrey and Borders Partnership
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
1. Mary was discharged from the Abraham Cowley Unit without a discharge planning meeting taking place in circumstances where there was no confirmation that she was eligible for housing provision and with no plan was to what would happen after the Travel Lodge placement ended. There is no policy in place which prevents a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit.
2. Mary was not subject to a medical review from the 28th March 2018 to the 26th May 2018. There is no policy in place which mandates when or if a patient should be subject to face to face review by a consultant psychiatrist after discharge from the acute unit.
3. No formal risk assessment was undertaken of Mary and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit.
4. The informal risk assessments undertaken in the Abraham Cowley Unit prior to her discharge failed to place any weight on the impact on Mary of a discharge with an inchoate plan for her housing and arrived at an incorrect assessment of her risk. The risk assessments were not sufficiently rigorous and evidence based.
5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA ( “ Care Programme Approach”) was not followed.
6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed.
7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with medication.