Daniel Clements
13 Jul 2022 · Coroner Kevin McLoughlin · West Yorkshire Western
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of safe care for suicidal individuals deemed not mentally ill
“How can a person displaying suicidal ideation be kept safe, if deemed not to be mentally ill?”
2. fragmented care leading to missed suicide risk
“In the fortnight before his death Mr [name redacted] had the following interactions with healthcare professionals”
3. inadequate multi-agency collaboration
“Mr [name redacted] was passed between agencies without any lasting benefit”
4. absence of legal authority to detain suicidal individuals without overt mental illness
“The Secretary of State for Health and Social Care is asked to consider whether an extension to the Section 136 Mental Health Act 1983 power is required”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Mr [name redacted] was passed between agencies without any lasting benefit.”
Later report
“there were only two attempts to see [the deceased] by the enhanced community mental health team”
Responses
2022-0209-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2022-0209-Response-from-South-West-Yorkshire-Partnership.pdf ↗· South West Yorkshire Partnership NHS Foundation Trust
Stated action
“the Trust will propose a meeting with its social care partner, [name redacted] Authority, to raise with them the contents of your report.”