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  • Prevention of Future Deaths report - Rebecca Romero (13 December 2017)


    Patient-Safety-Learning
    • UK
    • Reports and articles
    • Pre-existing
    • Public domain
    • No
    • Maria Voisin
    • 13/12/17
    • Everyone

    Summary

    Rebecca Romero was 15 years old and had a long history of self-harm and mental health problems. On 19 July 2017 she was found dead at her home, with a ligature around her neck. Rebecca had left Pebble Lodge psychiatric unit for a period of leave on 6 July 2017, but never returned to the unit after her leave. The original plan was to transfer her to an alternative unit, Riverside, but as there were no inpatient or day patient places available, a discharge meeting was held on 14 July where a community care package was put in place. She was under the community team at the time of her death, but had not been seen since her discharge.

    Content

    An independent witness at the inquest highlighted that:

    • Rebecca was at very high risk after discharge, and she did not have adequate medical review in between 6 July and her death on 19 July.
    • the plan to see her once a week after discharge was inadequate.

    In her report, the Coroner raised the following concerns:

    1. In this case there was confusion as to whether on an inpatient transfer there should be a Form 2 to go alongside the Form 1 procedure. As well as clarifying this process with all providers concerned, consideration should be given that a clear, documented process is put in place for inpatient transfers so that all the involved understand clearly the situation and the decision made in relation to the patient.
    2. Consideration should be given to ensuring that all care plans are time-specific so that dates of meetings of dates for tasks to be completed are set at the time of the meeting, so again expectations are managed and everyone knows exactly what the plan is and when actions will occur.
    3. That the issue of inconsistent terminology when assessing risk is reviewed to ensure a consistent approach. In this case there were a number of different phrases and gradings used to determine the deceased's risk.
    4. That consideration should be given to training and/or guidance issued for staff communicating with young persons by text or any means of social media.
    5. Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric inpatient care and further guidance issued in the management of children when returning to their local area when they have been an inpatient out of area. Whether certain steps should be taken to ensure best practice and a consistent approach, for example, risk assessing, face to face meetings, robust care planning, parental involvement and how to best reintegrate back into the local area/team.

    This report was sent to Avon & Wiltshire Mental Health Partnership NHS Trust, Dorset Healthcare University NHS Foundation Trust and NHS England.

    Prevention of Future Deaths report - Rebecca Romero (13 December 2017) https://www.judiciary.uk/publications/rebecca-romero/
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