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Shortcomings of NHS mental health services put lives at risk, according to Coroner’s report

Delayed mental health assessment of patients may give rise to a risk of loss of opportunity to identify signs of psychosis, a “prevention of future deaths” report revealed.

Timothy R Holloway, Assistant Coroner for the area of Blackpool & Fylde, wrote a prevention of future deaths report in relation to the death of Marlene McCabe, who “died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries.”

According to the report dated 11 June 2023, the actions of her assailant were “more than minimally contributed to by the assailant’s undiagnosed and untreated schizophrenia coupled with alcohol intoxication.”

On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. 

There were prior failures in the collation and consideration of information “in the mental health assessment of and progression of treatment for the assailant, in particular from early July 2019” which gave rise of the Assistant Coroner’s opinion that “there is a risk that future deaths will occur unless action is taken”.

Delayed mental health assessment is a matter of concern

Addressing the matters of concern to Bloomfield Medical Centre, Blackpool Teaching hospitals NHS Foundation Trust and Lancashire and South Cumbria NHS Foundation Trust, Holloway wrote: “There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made.”

In this case, the urgency of Primary Intermediate Mental Health Team (PIMHT) referrals was found to be of critical importance as the lack of appropriate response to the urgency led to the unlawful killing of Marlene McCabe.

Assistant Coroner also wrote: “There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse.”

“There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis,” Assistant Coroner added.

Another matter of concern in the report was the “inconsistent availability of access to mental health records across the service providers”.

Long waiting lists of mental health services are concerning

Nearly a quarter of mental health patients (23%) wait more than 12 weeks to start treatment, due to lack of consultant psychiatrists, according to research released last year by the Royal College of Psychiatrists.

The research reported that over two fifths (43%) say that the wait between initial referral and second appointment – the point when treatment usually starts – has caused their mental health to worsen.

“More than three quarters (78%) of those in a hidden waiting list reported that they were forced to resort to emergency services or a crisis line in the absence of mental health support – including 12% going to A&E, 7% ringing 999, 16% contacting 111 and 27% turning to a crisis line,” the Royal College of Psychiatrists reported.

“Waits can be longer than six months for 12% of cases, while 6% of patients wait for more than a year.”

“I had to wait six to seven months to be referred”

A mental health patient for more than ten years said what she experienced in terms of mental health care made things worse for her.

“I had to wait six to seven months to be referred to a community team. The only other way to get help was to present to A&E, which was a traumatic experience – having to be reassessed and readmitted again and again. Turning up to A&E was the only way I could be seen regularly. No one should have to go through that,” she said.

“What I experienced after I was discharged only made things worse. There is no help when you are discharged, and I found myself in this revolving door for ten years. I’m in a much better place, but services need to change so that people struggling with their mental health don’t have to wait so long to get help,” she added.

“NHS staff are at the sharp end of this mental health crisis”

Dr Kate Lovett, Presidential Lead for Recruitment, Royal College of Psychiatrists, said:

“We cannot sit idly by and watch the most vulnerable people in our society end up in crisis.

“Not only do spiralling mental health waiting times wreak havoc on patients’ lives, but they also leave NHS services with the impossible task of tackling rising demand.

“If we don’t train more doctors by increasing medical school places, waits will keep getting longer especially in underfunded specialties like psychiatry.

“Government needs to take responsibility for the fact that without decisive action on workforce, it’s denying patients timely access to lifesaving treatment.”

Dr Rosena Allin-Khan MP, Shadow Minister for Mental Health, also pointed out the problems in mental health services last week in a debate.

She said: “NHS staff are at the sharp end of this mental health crisis. I know them, I work with them, and I see what they are coping with daily.

“They’re heroes but they simply don’t have the resources, the staff of the leadership from ministers to do their jobs.

“They themselves suffer exhaustion, depression, stress and anxiety. Around 17,000 staff, that’s 12% of the mental health workforce, left last year.”

If you suffer from depression, stress or anxiety, there are various organisations for frontline workers such as ambulance staff and security workers to get confidential help for their mental health needs:

For ambulance staff, their family members, students and ambulance service volunteers

TASC – The Ambulance Staff Charity   

For medics and security industry professionals

SIU – Security Rehabilitation Centre

For serving and retired police officers

Police Care UK

Flint House – Police Rehabilitation Centre

For armed forces veterans

Combat Stress


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