Prevention of Future Deaths report – Azra Hussain

Summary

Azra Hussain died by suicide while a patient at Mary Seacole House, operated and staffed by Birmingham and Solihull Mental Health Foundation Trust. In their report, the Coroner raised patient safety concerns relating to her family being unable to participate in a multidisciplinary team meeting prior to her death due to Covid-19 visiting restrictions.

Content

The Coroner noted that Azra’s family had raised concerns about a suicide attempt that had not been subsequently recorded on her risk screen or included in handover information the following day to the multidisciplinary team (MDT) meeting. Due to restrictions relating to the Covid-19 pandemic, Azra's family could not attend that meeting to raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the day but was not made available to Azra's family nor was a telephone number to dial into the meeting.

The Trust had put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. The Coroner stated concerns about this as an alternative to being invited to attend an MDT, noting that:

• There is the potential that information will not be recorded accurately or will not be understood in written form.
• This doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views.

The Coroner stated that in their view there is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.