‘An appalling lack of communication’ - GP’s dismay following death of patient
PUBLISHED: 17:25 11 November 2019 | UPDATED: 08:49 12 November 2019
A GP has hit out at an “appalling lack of communication” from mental health and drug treatment services in the lead up to the death of one of his patients.
Victoria Robinson died aged 41 in September, with her cause of death being given as natural causes exacerbated by prescribed drugs, including methadone.
However, in the years leading up to death she received treatment for addiction and mental health issues, alongside the care of her GP, Klaus Koch.
Dr Koch, of Theatre Royal Surgery in Dereham, saw Miss Robinson, of Brooks Drive, Scarning, on more than 200 occasions between 2014 and 2019, during which time he prescribed medication to her.
However, Dr Koch told an inquest into her death that while Miss Robinson was also receiving treatment from Norfolk and Suffolk NHS Foundation Trust (NSF) and Change Grow Live (CGL), his surgery was left in the dark over her circumstances and what other medication was prescribed.
He said: "She had a very open relationship with me and I tried to give a reasonable amount of support, but her addiction became and over-whelming feature of her life.
"However, there was an appalling lack of communication from CGL and NSFT - the silence could be six months at a time."
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Area coroner Yvonne Blake said she would contact CGL and recommending they establish stronger lines of communication with GP surgeries in future to allow all the aspects of treatment to be better in sync in future.
Dr Bohdan Solomka, medical director at NSFT, said in a statement: "We are aware that Dr Koch raised a number of general concerns, covering a period of four years, at the inquest, mainly regarding communication with our services and concerns regarding services provided by CGL.
"We are pleased that Dr Koch's practice is willing to meet us with a view to improving communications between our organisations. "While we accept there is still scope for improving communication without or partner organisations, our internal investigations found that Miss Robinson's sad death was not linked to any care or service delivery problems."
Graeme Malcolm, services manager of Change Grow Live Norfolk, said: "Our sincere condolences go out to the friends and family of Victoria Robinson who tragically passed away in September last year.
"People accessing our services for support with drug and alcohol misuse may also be engaging with the Norfolk and Suffolk NHS Foundation Trust's (NSFT) mental health team, as was the case for Ms. Robinson. This underlines the importance of ensuring communication between NSFT and other support service providers is as efficient as possible.
"Change Grow Live in Norfolk currently operates using a GP-based Locality system, with our recovery staff based in many GP surgeries across Norfolk. NSFT and Change Grow Live have an Information Sharing Protocol, which along with NSFT's move to a Locality system and an agreement that our staff can refer urgent cases directly to the NSFT mental health crisis team, means that Change Grow Live and NSFT continue to develop closer co-ordination to safeguard people using our services.
"We have recently reached agreement for a NSFT clinician to be seconded to Change Grow Live to embed these links even further and develop Dual Diagnosis pathways for people with mental health conditions and related substance misuse.
"Anyone concerned about drugs or alcohol can call Change Grow Live Norfolk on 01603 514096 for support without judgement".
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