Dominic Noble

1 Jul 2022 · Coroner Kevin McLoughlin · West Yorkshire (Eastern)

The coroner's concerns

1. limited psychiatric availability
“HMP Leeds has only 3 days per week of a psychiatrist's time available”
2. delayed psychiatric assessment
“Mr [name redacted] was deemed to require assessment by a psychiatrist on 14 July 2020 as a non-urgent case but at the time of his death on 15 August 2020 no appointment had been given”
3. inadequate use of external psychiatric resources
“PPG could draw additional psychiatric input from elsewhere in the PPG group, but there was no evidence to indicate when, if ever, this was last done”
4. referral deterrence
“the meagre provision of psychiatric consultant availability might deter mental health nurses from making referrals”
5. treatment delay contributing to death
“it is possible that the delays in providing treatment contributed more than minimally to Mr [name redacted] death”
6. insufficient psychiatric staffing assessment
“PPG are asked to review the availability of psychiatrists at HMP Leeds to determine whether it is sufficient to meet the needs of a cohort of mentally unwell prisoners”