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recurance

Janet Blackman

29 Apr 2014 · Coroner Michael Burgess · West Sussex

The coroner's concerns

  1. 1. lack of physical health care in psychiatric units

    “The HKU like other units dedicated to the delivery of essentially psychiatric care are not able to deliver at least some of the elements required of the patient for her physical health”
  2. 2. lack of DVT prophylaxis in psychiatric units

    “It would seem that the logic of the DVT prophylactic policy as recommended by NICE is not applied to those patients coming into the psychiatric units - or if it were then Mrs [name redacted] would have been subject to the same clerking process on each of her admissions to the HKU and thereafter would have been able to receive the prophylaxis care that had been prescribed for her in the AMU”
  3. 3. fragmented care requiring patient transfers

    “It should be possible to develop a system enabling a seamless delivery of care covering both the physical and mental health treatment including DVT Prophylaxis to a patient in a single unit without the need to move patients physically from one unit to another”

Responses

No published response was found on judiciary.uk.

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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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