Re Mary Gwanyama (PFD report sent to Surrey and Borders Partnership)  MHLO 1
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.