Denton Duhaney
9 Jun 2021 · Coroner Mary Burke · West Yorkshire Western Division
The coroner's concerns
1. lack of psychiatric assessment and treatment
“Mr [name redacted] was a patient at Pinderfield's Hospital between 23 and 25" June but at no time was he assessed or receive treatment by the in house psychiatric team despite the fact that he had an underlying psychiatric presentation”
2. non adherence to discharge protocol
“Pinderfields hospitals discharge protocol does not appear to have been adhered to when Mr [name redacted] expressed a wish to self-discharge”
3. failure to notify home based treatment team
“No one from Pinderfield's Hospital contacted Kirklees Intensive Home Based Treatment Team to notify them of Mr [name redacted] self discharge”
4. delayed communication about patient status
“Kirklees Home Based Treatment Team last had contact with Pinderfield's Hospital on 24'" June 2019. It was 6 days later that they made a further call to the hospital seeking an update upon Mr [name redacted]”