“evidence is that on several occasions during Ms”

The coroner’s concerns

a. evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with . The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. 2 b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF. c. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community. Although not causative of the death and I noted ’ very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern. d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP. I received further evidence in writing from the Interested Persons’ subsequent to the completion of the Inquest in relation to these concerns. This evidence included a response from Surrey and Borders Partnership NHS Foundation Trust (SABP) concerning the measures which have been put in place to address the failures identified during the course of the Inquest. These measures included: 1. The introduction of a clear discharge pathway (including risk assessment and care planning), with a clear role for the discharge coordinator and strengthening of the lead nurse involvement. 2. The introduction of a discrete role to liaise and engage with family (including where this may need to come from different family members) to collect collateral information relating to a patient. 3. The use of a mental health services multi-disciplinary team (MDT) to identify where possible gaps in patients previous medical history. 3 4. The introduction of measures to increase collaboration between in-patient and community mental health services. 5. The use of an SABP duty team member to monitor SCARF messages left in group e-mail boxes out of hours. I was satisfied that these measures addressed the concerns in relation to subparagraphs c & d above. I was also satisfied that the measures introduced by SABP in relation to sub-paragraphs a & b have addressed my concerns in relation to SABP’s involvement in those areas. However, I remained concerned in relation to the matters identified at subparagraphs a & b (above). 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: There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians. The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0100

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0