“During the inquest evidence was heard that: i”

The coroner’s concerns

1. During the inquest evidence was heard that: i. At the time of her death Emma had a Frequent Attender Care plan, or as they are now known a High Intensity Use Care Plan, in place. This plan was agreed by representatives from Dorset Healthcare NHS Foundation Trust (DHUFT) who provide the mental health care across Dorset, a representative from the Royal Bournemouth Hospital, a representative from Poole Hospital and a representative from We Are With You (WAWY) who supported Emma with her substance misuse. The aims of this plan for Emma were: • to provide a consistent approach when Emma presented to the emergency department • to streamline her care so that she does not have to wait any longer than necessary in the ED as she has identified this makes her feel worse • to minimise the impact on emergency department resources when Emma attends • to reduce the use of restrictive interventions which may exacerbate Emma’s distress ii. South West Ambulance Service NHS Foundation Trust (SWAST), who provide the paramedic care in the South West, were not provided with the plan prior to the 14th March 2023, nor were other hospitals Emma may present to, such as the other local hospital in Dorset, Dorset County Hospital, or the hospital in 2 Cornwall where Emma was taken to when she self harmed on the 5th March 2023 during her time at the detoxification and rehabilitation placement. iii. On the 14th March 2023, due to the capacity issues the cohorting area was opened at the Royal Bournemouth Hospital and representatives from SWAST were caring for the patients in the cohorting area. When Emma arrived at the hospital, she was taken to the cohorting area and was booked into the hospital by the triage nurse from the hospital, although was not seen by them and her previous records were not accessed. iv. There can be a delay in accessing the hospital patient record when a patient arrives at the hospital as following the booking in process, there needs to be a merger of the ambulance paperwork to verify they have the correct person before the hospital patient record can be accessed. The process adopted by different hospitals may cause a delay in access to the hospital patient record and evidence was given that at the Royal Bournemouth Hospital this could be anything up to 10 minutes from experience. v. When Emma arrived at the hospital she was booked in by the triage nurse between 18.49 and 18.52 hours, however the merger of her records did not happen until 18.59 hours. No representative from the hospital saw Emma prior to her death and she was monitored by the SWAST paramedics in the cohorting area, so there was no access to her patient record which detailed her significant history of self harm and the Frequent Attender Care Plan. The Frequent Attender Care Plan was not followed throughout the 1 hour and 47 minutes Emma was with professionals from when SWAST attended her home address until the time she was last seen prior to her death. Had it been accessed, and followed, there would have been opportunities to discuss with Emma further support for her whilst she was at the hospital and the evidence given by the witnesses who had contact with her that day was that they would have considered managing her care differently. vi. University Hospitals Dorset NHS Foundation Trust, of which the Royal Bournemouth Hospital forms part, have taken action internally to ensure that a person’s records are now available when a person arrives at the hospital and this would include access to Frequent Attender Care Plans, however evidence was given that a similar process around the merger of records is undertaken at other hospitals across the South West, from the experience of SWAST, and this may also be a national issue. vii. The Summary Care Record (SCR) is accessible to a variety of healthcare professionals and accessible to SWAST. 3 viii. As per the NHS England website, link found here Summary Care Record - NHS England Digital, “The Summary Care Record (SCR) is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care”. ix. Documents cannot be uploaded to the SCR, however a section can be added to the SCR to detail information such as care plans. Evidence was given that the content of the SCR is controlled by the specific Integrated Care Boards (ICB) covering that area. There are 42 ICBs across England and Wales. x. The SCR for Dorset does not include a section to detail the care plans in place for individuals. The Deputy Director for Care for SWAST gave evidence that none of the ICBs in the South West Region has a section in the SCR to detail care plans in place for individuals. IF there were such a section, the GP of the individual would then be responsible for uploading the details to the SCR and then it would be accessible to other health professionals the person comes into contact with nationally. 2. I have concerns with regard to the following: 6 i. There can be a delay in accessing a patient’s hospital record and history when they are taken to hospital by a paramedic depending on the method of booking in and triage which could impact on patient care, especially if there are delays in them being assessed such as when they are placed in cohorting areas, and this could lead to a future death. ii. The Summary Care Record does not detail care plans in place for individuals in Dorset, the wider South West region and may be nationally. Lack of access to these plans could impact on patient care and lead to a future death.

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, 2024-0646

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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