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Forewarned is Forearmed


In June 2022, a Channel 4 News investigation uncovered the grim statistic of an 800% increase over the past five years of coroners issuing official warnings about cases involving mental health issues.[1]

In England and Wales, the number of ‘Prevention of Future Deaths Reports’ (PFDs) classed as mental health-related had risen from 16 in 2017, to 126 in 2021. As of May 2022, there have already been 52.

Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority, government department or other agency where the coroner believes that action should be taken to prevent future deaths and to address concerns arising from inquests. Given the increase in mental health-related PFDs, we have considered these reports and set out a few considerations to help minimise the risks posed.

Initial Assessments:

A recurring theme within many recent PFDs is the reference to ‘missed opportunities’.

Many providers will receive initial referrals from a local trust, social worker or directly from a hospital. The referral will contain specific details surrounding the patient, the reasons for their referral and, quite often, a social and medical background. It is imperative that providers review and scrutinise their respective referral processes and to consider whether full and in-depth detail regarding the patient has been provided.

There have been cases where important details surrounding a patient’s history or medical background are overlooked and not passed on from agency to agency. There are often many different agencies involved in front-line mental health care, ranging from doctors to community mental health teams, key workers, etc. Information can be lost. A review of the initial assessment process will ensure a wider and more detailed capture of all information. 

Risk Assessments:

A provider must ensure that a fully integrated system of risk is in place which includes not only service users, but also staff and the organisation as a whole. It starts immediately at the initial referral process. Taking a structured approach will certainly assist with considerations, such as establishing the context in which a service user is referred, from which agency, and in what circumstances. It also follows that a provider ought to identify the particular risks, assess these risks and finally, not just take reasonable steps to control any known risk, but monitor it as well.

Although risk will never be eliminated completely, it can be minimised by implementing good practices and procedures which are routinely evaluated.

Monitoring and Evaluation:

Whilst already common practice amongst most healthcare providers, implementing a regular and scheduled monitoring process is key. Consistent analysis, alongside a ‘lessons learnt’ type event will help keep providers ‘ahead of the game’ as risk does not stand still.

In conclusion, the rapidly evolving mental health problems in society offer a wide range of challenges for providers. Whilst a PFD may be considered a criticism, the consistent nature of recommendations being outlined by coroners offers an opportunity for providers to remain vigilant and avoid tragic incidents. Forewarned is, indeed, forearmed.

[1] https://www.channel4.com/news/catastrophic-collision-of-failures-revealed-in-mental-health-services

Abdul Khan

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