'Overconfident' non-clinical staff may not understand impact of their decisions, coroner warns

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By Daniel Pye

A coroner has warned that the care of a patient who later died by suicide included “missed opportunities” and delays to see a doctor – including an appointment with a Band 4 member of staff who did not refer him on.

David Roomes, who had bipolar affective disorder, had an appointment that included a Dialog+ assessment. This tool is used to assess risk via a series of questions, and was used by a non-clinical member of staff at Kent and Medway Mental Health NHS Foundation Trust (KMMHT).

In a prevention of future death report following an inquest into the death, the coroner said he was told in evidence that Roomes, who had a complex medical history, should have been “seen by a qualified clinician at that appointment”.

The coroner said he was concerned that non-clinical decision-makers could potentially be "over-confident" and not fully understand the risks of certain decisions.

“The Band 4 member of staff who undertook the assessment was content with their assessment and the plan that was formulated as a result of it,” coroner Ian Potter wrote.