Missing records scandal

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A WIGAN children’s mental health service lost the personal files of 12 vulnerable youngsters in the space of just six months this year.

Information obtained exclusively by the Wigan Evening Post reveal that between April and October 2011, the individual cases documents of a dozen children referred to the Child and Adolescent Mental Health Service (CAMHS) were mislaid.

This rocketed from just two sets of documents in the four previous years.

The information came just two months after a coroner ordered a shake-up of the service following the inquest of a teenager, who was found hanged a month after being referred to staff as being in urgent need of help.

Poppy Bracey, whose case documents were lost, was just 13 when she was found hanged from her bedroom door at her foster parents’ home in Bridgewell Drive, Leigh, on March 1, 2010.

The policy of CAMHS is to action all urgent cases within 24 hours of them being brought to the attention of staff, but because the teenager’s documents were lost, contact was never made and she never got the help that she needed.

Her documents were only found after her death. They had been put into the wrong filing cabinet.

From April 2007 to March 2008, just one document was lost (permanently disappeared) or misplaced (lost but later found), and the only other year which had the same result was 2009/10.

In the six months from April 2011, 1,480 referrals were accepted into the children’s mental health service, and 91 of those were urgent.

According to data provided by the 5 Boroughs Partnership, of which the CAMHS is part, just one of those urgent referrals was not seen within 24 hours, because the individual absconded from a hospital ward before they could be seen.

And although it is not recorded in the data given to the Evening Post, there was an additional urgent referral not seen within the prescribed 24 hours in 2010/11. This was the case of Poppy, who was a Lowton High School pupil.

Before 2010, information about urgent referrals not seen before the prescribed time was not recorded.

In the year that Poppy died, 176 out of the total 2,775 referrals made to the service were urgent.

As a result of the tragic teen’s death an independent multi-agency review board was launched, and from it five recommendations were made.

The review also found that there was “mishandling of the referral document and the inappropriate filing of information”.

A spokesman for the 5 Boroughs Partnership, said: “As a result of the coroner’s recommendations we have undertaken an intensive audit designed to link every patient with their case file.

“We therefore see the sharp increase in the number of case notes that have been reported as lost or misplaced in the past six months as a positive reflection of this important work.

“Of the 12 missing case notes, nine are now located.

“For the remaining three, we have been able to create a new set of records from electronic data to ensure that care for those patients is not adversely impacted.

“None of the missing files related to children who were referred to our Child and Adolescent Mental Health services as an urgent case.

“With regard to our referral process, we have introduced a whole new system to ensure every referral is checked and validated.

“The journey of a referral through our service is now mapped so that it can be monitored at every stage.”