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recurance

Jane Bush

20 Oct 2021 · Coroner Jacqueline Lake · Norfolk

The coroner's concerns

  1. 1. delay in mental health assessment

    “[name redacted] was referred to the mental health team in November 2019 and was assessed in January 2020, some three weeks later than should have been.”
  2. 2. delay in psychological therapy

    “There was a delay in [name redacted] receiving psychological therapy. She was still on the waiting list at the time of her death.”
  3. 3. delay in psychological therapy due to capacity-demand imbalance

    “The evidence was that at the date of inquest, there continued to be a delay in service users receiving psychological therapy. Evidence was heard that balancing capacity and demand, which has increased, remains a challenge. The cases referred are of increasing complexity, as in [name redacted]'s case”
  4. 4. staff recruitment and retention issues

    “However, there is the ongoing issue of recruitment and retention of suitably skilled staff by the Trust and the ability to resource this to enable the Trust to function effectively”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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