Darren Lawrence
15 Oct 2021 · Coroner Nigel Meadows · Manchester City
The coroner's concerns
1. inadequate follow up during transfer between services
“The transfer and communication process from the HBTT to the CMHT in 2019 and 2020 was unsatisfactory with inadequate follow up as required”
2. failure to escalate when patient disengages from services
“There was lack of appropriate escalation following the deceased's disengagement with community services in 2019 but also in 2020 when there was a repeated lack of direct contact with him as well as the recognition of its importance”
3. missed opportunity to refer back to intensive support
“There was no consideration of referral back to the HBTT by the CMHT when the deceased may have benefited from it when circumstances changed”
4. lack of medication monitoring process
“There was no GMMH procedure or process to check regularly if the deceased was being prescribed the correct medication and it being collected”
5. failure to prescribe essential medication
“The GP practice failed to ensure that medication (for a patient with a serious mental health problem with a history of suicidal ideas, plans and previous attempts) was prescribed”
6. inadequate correspondence tracking system
“The GP system for recording receipt of correspondence and ensuring that they were seen and reviewed by a GP was inadequate”