Jillian Steedman
10 Oct 2025 · Coroner Sonia Hayes · Essex
The coroner's concerns
1. lack of information sharing between professionals
“lack of information sharing between professionals involved in the care and treatment of [the deceased] who was a complex mental health patient with a long history of treatment resistant mental disorder”
2. consultant not informed of mental health deterioration
“Mrs [name redacted] consultant responsible for ongoing Electroconvulsive Therapy (ECT) was not informed of her mental health deterioration”
3. incomplete care plans risk assessment and procedures
“mental health Trust staff involved in the discharge and community care of Mrs [name redacted] were put on notice by a clinical lead on 16 March 2023 that the care plans, risk assessment and procedures relevant to the discharge had not been completed and were required in addition to the integrated plan that was attached to the email. These were never completed”
4. inappropriate placement and outdated care plan
“Mrs [name redacted] was discharged to the care home on 11 April 2023 from mental health hospital following an admission of over 12 months and previously failed discharges. Evidence was heard Mrs [name redacted] was not appropriately placed in the Care Home based on her needs and the local authority were on notice that another care home had refused to admit Mrs [name redacted] due to her mental health. There was no review and the s117 care plan had not been updated since 13 September 2022”
5. failure to complete required reviews
“Visiting Professionals did not complete the required reviews necessary when Mrs [name redacted] was distressed and experiencing crises”
6. lack of placement appropriateness review after crisis
“The appropriateness of the placement was not reviewed following a crisis on 15 April 2023 just a few days after admission”