John Kirkman
8 Jul 2025 · Coroner Paul Marks · Kingston Upon Hull and the County of the East Riding of Yorkshire
The coroner's concerns
1. lack of immediate availability of screening assessment results across regions
“Evidence was heard that if a mental health screening assessment is carried out in one part of the country, the results and conclusions reach may not necessarily be immediately available in another part of the country, when a further assessment is carried out”
2. incorrect prioritisation of mental health referrals
“Absence of vital background information could result in an incorrect prioritisation for onward referral as it did in this case”
3. screening not linked to formal assessments
“Screening may form the basis for onward referral for formal mental health assessments”