Antony Schofield
27 Sept 2021 · Coroner Nigel Meadows · Manchester City
The coroner's concerns
1. lack of comprehensive risk review prior to discharge
“No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit”
Responses
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published.pdf ↗· Greater Manchester Mental Health NHS Foundation Trust
Stated action
“(a) No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the Deceased prior to his discharge from the Inpatient Unit. This was not identified before he left the ward, and it was not discovered by the HBTT when they took over his care.”