Trevor Curry

[REDACTED], Chief Executive, Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing. BN13 3EP

I am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove

On 17th June 2016 I commenced an investigation into the death of Trevor John CURRY. The investigation concluded at the end of the inquest on 1yth March 2017. The conclusion of the inquest was a Narrative Conclusion – see attached sheet.

See Record of Inquest

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) It is nationally acknowledged that there are a growing number of patients in both acute and psychiatric hospitals and prisoners who have substantial mental health and physical problems.                                   This is particularly the case in view of the ageing hospital and prison population. It is therefore incumbent upon those caring for such people to ensure that they have full mental and   physical past medical histories. In this particular case at Inquest, I accepted that the deceased’s sister had informed the triaging and admitting staff atthe psychiatric hospital of the fact that he was being seen by the Cardiologist and was suffering with heart problems (i.e. palpitations). No note was made of this in Mr Curry’s admitting note. It should have been. In addition, the psychiatric trust made no effort to ascertain his full past physical history until after he had died. Of course they were not expecting  him to die within 48 hours of admission but that is not the point. Enquiries of this nature should be made at the earliest opportunity and if there are no reciprocal IT arrangements  then the individual trusts must have arrangements between them so that they can access appropriate history speedily. This is particularly important in cases where a patient is admitted to a psychiatric hospital in an agitated, even psychotic state and unable to give an appropriate history him or herself.

In my opinion action should be taken to prevent future deaths and I believe you AND your organisation have the power to take such action.