28 Sep 2017 GILLIAN O’KEEFFE · Prevention of Future Deaths report London Inner (West)
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Concerns raised 5 Unlikelihood of self-referral by patients unable to engage with mental health services View source Inappropriate discharge of patients in greatest need of mental health support for non-engagement View source Failure to coordinate pre-discharge handover and transition with the GP surgery View source Lack of an accessible mechanism for families to share mental health concerns with the professional team View source Lack of a procedure for following up urgent GP concerns or referrals View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
GILLIAN O’KEEFFE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gillian O’Keeffe had a serious mental illness and died at home on 19 March 2017 after taking her own life while the balance of her mind was disturbed. The concerns included her discharge from community mental health services for non-engagement despite family and professional concerns, inadequate communication with her GP and family, and the absence of a clear process for following up urgent concerns or referrals.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cricket Green Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Unlikelihood of self-referral by patients unable to engage with mental health services
Wider context from the report “(2) In view of her history and the inability of the Trust or GP surgery to make contact with Mrs O’Keeffe it was highly unlikely that she would self-refer .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cricket Green Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Inappropriate discharge of patients in greatest need of mental health support for non-engagement
Wider context from the report “(1) That the decision to discharge Mrs O’Keeffe ‘for non-engagement’ from the local Mental Health NHS Foundation Trust care in January 2017 appeared illogical when it was likely, having regard to the facts, that she was in greatest need of their help : she was a service user of long standing, she had an acute deterioration in her mental state in March 2016, that there had been concerns raised by her family in October 2016 and that no professionals had been able to make visual contact with her since October 2016.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cricket Green Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate pre-discharge handover and transition with the GP surgery
Wider context from the report “(3) There was no pre-discharge multidisciplinary meeting to include and inform the GP before discharge nor attempt to ensure that there was a seamless transition to the GP surgery .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cricket Green Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of an accessible mechanism for families to share mental health concerns with the professional team
Wider context from the report “(5) There appeared no easy or appropriate way that the family were able to share information and their concerns about Mrs O’Keeffe’s mental health with the professional team , consequently, notwithstanding the family’s continual and concerted attempts to notify Mrs O’Keeffe’s care co-ordinator, they felt that the professionals were unaware of the parlous state of Mrs O’Keeffe’s mental health and the family’s serious concerns .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cricket Green Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for following up urgent GP concerns or referrals
Wider context from the report “(4) Evidence was given at the inquest that there was no procedure or policy in place at the Trust to follow up GP concerns or referrals particularly where there was likely to be a degree of urgency .
” Open source report