| Display title | Re Mary Gwanyama (PFD report sent to Surrey and Borders Partnership) [2021] MHLO 1 |
| Default sort key | Re Mary Gwanyama (PFD report sent to Surrey and Borders Partnership) (2021) MHLO 1 |
| Page length (in bytes) | 5,139 |
| Page ID | 12943 |
| Page content language | en - English |
| Page content model | wikitext |
| Indexing by robots | Allowed |
| Number of redirects to this page | 0 |
| Counted as a content page | Yes |
| Edit | Allow only users with "editing" permission (infinite) |
| Move | Allow only users with "editing" permission (infinite) |
| Page creator | Jonathan (talk | contribs) |
| Date of page creation | 20:18, 24 April 2021 |
| Latest editor | Jonathan (talk | contribs) |
| Date of latest edit | 11:54, 8 October 2021 |
| Total number of edits | 7 |
| Total number of distinct authors | 1 |
| Recent number of edits (within past 90 days) | 0 |
| Recent number of distinct authors | 0 |
Description | Content |
Article description: (description)
This attribute controls the content of the description and og:description elements. | 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). |