Billy Jenkins
21 Feb 2020 · Coroner Jacqueline Devonish · London South
The coroner's concerns
1. insufficient information gathering leading to missed mental health diagnosis
“The findings of the internal investigation by Oxleas NHS were that the assessment undertaken by the Community Mental Health Nurse did not illicit sufficient information to enable the multidisciplinary team to properly review Mr [name redacted]' mental health. Despite this the multi-disciplinary team proceeded with a review and decided that he did not have a mental health condition, without seeking a further assessment”