David Fowler
20 Dec 2019 · Coroner Rachel Galloway · Manchester (West)
The coroner's concerns
1. family not invited to MDT meeting
“no steps were taken to invite Leeann (or any other family member) to the MDT meeting on the 18"" December 2018 when the decision was made by the Responsible Clinician to remove [the deceased] from the confines of section 3 (and section 17) of the Mental Health Act 1983”
2. absence of formal policy for family contact
“there was no formal Policy in place covering contact with families in respect of the above decisions and/or in respect of inviting family members to MDTs more generally”
3. confusion over responsibility for family notification
“there was on-going confusion between witnesses (in particular the Acting Manager and the Responsible Clinician) as to who is tasked with informing the family of MDTs and of any potential decision to remove a "section”