Jake Read
17 Jun 2026 · Coroner Nigel Parsley · Suffolk
The coroner's concerns
1. lack of national guidance or timelines for medication administration in mental health agitation or crisis
“evidence heard that there is no national guidance or timelines in place for the administration of medication required in cases where an individual has been identified as being in a state of Mental Health agitation or Mental Health crisis”
2. absence of clear medication administration timelines in mental health cases
“Evidence heard that in some medical cases clinical staff are given a clear timeline in guidance as to when it is expected a required medication is to be administered (sepsis being cited as an example)”
3. restricted prescribing authority for non-medical prescribers in emergency departments
“Evidence was heard that the East Suffolk and North Essex NHS Trust and the Norfolk and Suffolk Foundation Trust have changed the system at the Ipswich Hospital, and now the Mental Health Liaison Team Non-Medical Prescribers are able to both prescribe and access prescription medications within the Emergency Department, without the need to request an Emergency Department clinician to prescribe it for them”