Christopher Bird

“During the course of the Inquest, I heard evidence [REDACTED] from [REDACTED] the joint Senior Partner at The White Horse Medical Practice. Having asked colleagues to carry out a forensic search for evidence of the e-mail having been received and finding none he did allude to a view that was not shared by him alone, but by colleagues both within the Surgery and it appears colleagues in other surgeries that there were concerns that when using the nhs.net e-mail that e-mails had gone missing and were not received through the system questioning its 100% reliability. I personally have not come across another case where this issue has been raised but there is no evidence that I saw that pointed to the e-mail having been incorrectly sent by mental health to the GP practice and I have to accept [REDACTED] evidence that there is no evidence to support it was in fact received. The systemic failure here in my view more than minimally contributed to the deterioration in [name redacted]' mental health that led to his death late afternoon on the 19 September 2024. When [name redacted] spoke with another GP on the 16 September 2024, she was unaware of the response from mental health because the e-mail indicating in detail the nature of that response was never received by the GP practice. She in turn contacted the embedded mental health social worker the next day via e-mail although however he was not available that day hence the assumption that that was the reason if not a combined reason for [name redacted]' case being discussed at the hub meeting on the 19 September 2024. If there is a reliability issue with the use of nhs.net for whatever reason such as old infrastructure, then that clearly is a concern and one which I am of the view could impact on future deaths if important information having been sent through the system is not guaranteed to be received and is lost”