Gary Leyland
20 Nov 2019 · Coroner Joanne Kearsley · Manchester (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of contact with medical services
“Due to the fact Mr [name redacted] was residing in supported accommodation the Probation Officer reported her concerns to the Spring Street. However no attempt was made to contact any medical practitioner ie GP or mental health services. It was unclear at the conclusion of the Inquest whether there is a policy within the Probation for staff indicating to whom concerns should be raised for example if Mr [name redacted] had been residing in his own home and where the risk is not believed to be imminent although clearly”
2. inadequate documentation
“The Court found the recording and documentation to be of a poor quality and standard. The chronology document was not complete, information as to when Mr [name redacted] had been seen was missing. The observational log was completed in some instances with the use of an X as opposed to the staff members initials so it was not clear if he had been seen and if so by whom.”
3. lack of welfare check updates
“Only the handover sheets for the 7" and 8" November were updated to advise staff to "keep an eye" on Mr [name redacted]. NO updates were on the handover sheets for the 9-12" November despite the evidence being welfare checks would still have been expected on these dates. It is therefore unclear how security staff working the 10" and 11" November (weekend) would have been aware of the expectation to check on Mr [name redacted].”
4. missing risk assessment
“The Court heard there was no updated risk assessment conducted as was envisaged following the email from the Probation Service.”
5. absence of suicide policy
“The Court heard evidence that Oldham Council who commissioned the supported accommodation through Jigsaw Homes Group. The Court heard evidence part of the contract provision for the service includes the fact that Threshold ( the branch of Jigsaw Homes which provided the Spring Street accommodation ) must comply with certain policies which included risk assessment and risk management and Safeguarding Adults. However no evidence was provided to the Court as to any self-harm or suicide policy”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“However no attempt was made to contact any medical practitioner ie GP or mental health services.”
Later report
“The lack of knowledge of the Probation officer as to the services she could contact to obtain necessary mental health assessments.”