David Sewell
7 Sept 2017 · Coroner Andrew Barkley · South Wales Central
The coroner's concerns
1. lack of robust system to ensure individuals with mental health problems are seen and appropriate care delivered
“lack of a robust system to ensure that individuals with mental health problems, who may have experienced psychotic episodes as Mr [name redacted] had, are seen and appropriate care delivered”
2. discharged from case load with no further efforts to re-engage
“discharged from the case load with no further efforts or steps being made to try and re-engage him”
3. no further follow up
“no further follow up was made”
4. hostility towards team members during contact
“He was contacted by telephone on 3 occasions on the 16" and 17 August but displayed hostility towards members of the team”
5. decision to discharge if no contact made
“case was discussed by the Multi-Disciplinary Team on the 18" August 2016 who decided to write a letter him which was sent on the 26" August inviting him to make contact or otherwise he would be discharged from the Teams care”