Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of approved mental health practitioner for assessment
The earlier warning
Leah Ratheram · 15 Mar 2017 · Louise Hunt, Birmingham and Solihull
“The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed.”
judiciary.uk/prevention-of-future-death-reports/leah-ratheram
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 22 Jul 2019 · Richard Carlon · Louise Hunt · Identical hazard · confidence 0.90 (high)
- 4 Mar 2025 · Matthew Lynch · Louise Hunt · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Leah Ratheram · 15 Mar 2017
“The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed.”
Later · Richard Carlon · 22 Jul 2019
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
What happened next
No web check of the stated actions has been published for this chain.