A coroner has demanded more funding to be invested into Nottinghamshire’s mental health services after the death of a West Bridgford woman.
Kate Dolby, 36, was under the care of Nottinghamshire Healthcare NHS Foundation Trust when she was found dead at her home on October 9, 2016, after taking an overdose.
Heidi Connor, assistant coroner for Nottinghamshire, was left with concerns about the handling of Ms Dolby’s care after conducting an inquest into her death earlier this year.
But her biggest concern was a lack of funding available for staffing, so she has sent a Regulation 28 Report to Prevent Future Deaths to NHS Nottingham City Clinical Commissioning Group (CCG) asking it to take action.
The CCG has 56 days from the date of the report to send a response to the coroner, detailing any action taken or proposed.
The report, published yesterday (August 29), details evidence heard during the course of the inquest, which concluded on March 28 this year, about Ms Dolby’s care.
She was admitted to Millbrook Mental Health Unit, in Sutton-in-Ashfield, in April 2016, after suffering an “acute psychotic episode” and was referred to the trust’s Early Intervention in Psychosis (EIP) team.
The report states: “We heard that there are two EIP teams – one for city and one for county. The call was made to the county team. Kate’s GP surgery is based in the city.
“The call, it was also suggested, did not provide enough information for the referral to proceed. Common sense suggests that more information should have been requested, and the referral passed to the correct team.
“Instead, only a week later, the referral was simply closed.”
The breakdown in communication meant Ms Dolby was only re-referred to the EIP team in June last year, after her discharge from Millbrook in May.
But she “went to the back of the queue again” at a time when there was “a significant waiting list”.
Over the following weeks, Ms Dolby’s GPs became increasingly concerned about her and feared she was “in the early stages of a psychotic relapse”.
She was triaged by an EIP nurse, who also feared she was at risk of relapse, in July but she wasn’t seen again by the team until September.
Ms Dolby was described as the happiest she had been “for a long time” just a couple of days before her death.
According to the report, Nottinghamshire Healthcare requested funding for six nurses and a full-time consultant from the CCG for the EIP team.
But in April, funding had only been agreed for “three care-coordinators, an administrator, and 0.4 medic”, sparking Mrs Connor’s report.
She wrote: “There were undoubtedly failings and communication breakdowns contributing to the delay in Kate’s case.
“However I find that the most significant factor in the delay was workload and waiting list. This was the key cause, certainly from June 3, 2016, onwards, which is very much the bigger part of the delay in this case.
“The trust has addressed most of these issues and I therefore see no benefit in addressing this report to Nottinghamshire Healthcare NHS Foundation Trust as well. The key area of outstanding concern relates to funding.”
Dawn Smith, chief officer of NHS Nottingham City CCG, said there are “clear lessons to be learned” from the case.
She said: “We have provided the trust with an additional £284,000 funding package to meet national standards for EIP services and note the improvements they have made in reducing waiting times for patients.
“The service experienced an exceptionally high level of demand in Nottingham during 2015/16 that far exceeded national as well as local forecasts – rising by 50 percent from the previous year – but we have worked in partnership with the trust to meet their business case for ongoing investment.
“The trust is now consistently achieving the national target of seeing more than 50 percent of patients within two weeks, while improvements to staffing have reduced the case load size for care coordinators.”
A spokeswoman for Nottinghamshire Healthcare expressed her condolences to Ms Dolby’s family and friends.
She said: “New national targets have been introduced for EIP teams, which includes a requirement to assess and begin treatment within two weeks of referral.
“We are meeting these national targets, with all referrals now made via a single point of access and a care coordinator allocated within two weeks of referral being received.
“In addition, the coroner highlighted funding as a contributing factor to workloads and waiting times. The trust has appointed an additional three nurses since this time, increasing the number of EIP nurses to 18 within the city team.
“The trust has requested additional funding from Nottingham City CCG to maintain these increased staffing levels and ensure that it continues to meet the demand for this service.
“We know that these changes are too late for Kate but we hope that these will significantly reduce the risk of this happening in the future.”