Coroner warns of lack of continuity of staffing in home-based mental health care

A coroner has warned that a lack of continuity of staffing in home-based NHS mental health treatment services poses a risk to patient safety.

In a Prevention of Future Deaths (PFD) report into the suicide of Scott Donoghue, coroner Lorraine Harris warned the Department for Health and Social Care that the problem required ‘imminent attention’.

In May 2022 Donoghue, aged 33, went to the Humber Bridge with the intention of ending his life. After being taken by police to a mental health unit in Hull, he opted for treatment by the local NHS Home Based Treatment Team (HBTT), an alternative to hospital treatment that is available across the country.

However, during this time he raised concerns at the lack of continuity of staff that were assigned to oversee his care plan.

‘Mr Donoghue raised concerns on more than one occasion about the lack of continuity of the people overseeing his care,’ Harris wrote in the PFD report, ‘he specifically told [the HBTT] that he could sometimes put on a front with new faces to make him look okay when he was actually struggling.’

Harris said that this lack of continuity ‘more than minimally hindered his ability to engage and receive the best level of care’.

The HBTT conducted a series of visits while he waited for a date to be transferred to the community mental health team, where he would have had one person overseeing his care. He took his own life on 24th May 2022.

‘Due to the need for 24 hour a day/7 days a week HBTT service, the court heard that continuity of care by either one person or a small group of people was not possible,’ the PFD report said.

‘It was evident that the lack of consistency in staff dealing with Mr Donoghue’s care was a factor in his ability to engage and be honest with those having oversight of him at a very fragile time in his treatment.’

Harris added: ‘Although peoples’ care in HBTT had improved, a real continuity of staff could only occur with a substantive change which would include additional funding, recruitment of appropriate staff and an ability to retain staff. I was informed that if these issues were addressed it would allow more capacity to manage consistency alongside the other demands of the service.’

She concluded that ‘acknowledgement of the important work undertaken by HBTT and the need to give the very best support to those who have taken the, often difficult, step of seeking help with their care is a matter that requires imminent attention.’

The Department has until 24th November to respond.

Image: Alex Boyd

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