David Moran · Prevention of Future Deaths report

On 20th July 2016 an investigation was commenced into the death of David Moran aged 49. The investigation concluded at the end of the inquest on 4th January 2017. The conclusion of the inquest was that the deceased who died as a result of a metformin overdose took a fatal overdose of his medication but that his intention in doing so could not be determined.

The deceased who suffered from bi-polar affective disorder had a history which included suicide attempt and suicidal ideation. During a period of relapse he was contacted by a nurse from the Trust’s Warrington Assessment Team following a notification of concern from the deceased’s brother. The nurse attempted to complete the Trust’s screening tool without success. Trust Guidance set three levels of priority in dealing with referrals depending upon whether the need to see and assess the patient could be categorised as an emergency, as urgent or as routine. The nurse assessed the referral as routine. Subsequent to the nurse’s conversation with the deceased, his brother telephoned your service on not less than two subsequent occasions voicing increased concerns for the deceased but the calls were neither logged by the administrator who will have taken the call or entered within medical records with the result that an increasingly urgent need for assessment was not identified.

(1) The Trust Guidance for categorising the urgency of a referral appeared imprecise. Further, in that the referral system will often depend on a telephone conversation only, there did not appear to be a default to urgent in a case where a screening assessment was not possible or in a case of doubt or ambiguity.
(2) Communication between administrative staff and nursing / clinical staff did not appear to be effective.