Absence of mental health liaison during 72‑hour hold and missing discharge note

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2024 → 2025Nicholas Gray1 year after Aaron Deeley · same coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both concerns involve the absence or inadequacy of mental health liaison involvement/records for patients needing assessment. The earlier report notes a gap in liaison attendance during up to 72‑hour waits, while the later report highlights a missing record of a liaison nurse review on a specific date.

  Aaron Deeley · 19 Jun 2024

  “During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm”

  Check it in the source

  Nicholas Gray · 5 Jun 2025

  “There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr [name redacted] from EPUT.”

  Check it in the source

  Stated action in the response to the earlier report

  “In order to strengthen collaborative working across the two Trusts, a project group for development of the 'joint protocol' is being put into place. The first meeting with attendees from both Trusts has been arranged for 23rd September 2024”

  Earlier report in the app · Later report in the app