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recurance

Kim Morris

27 Aug 2019 · Coroner Lydia Brown · Leicester City and Leicestershire

The coroner's concerns

  1. 1. lack of continuity of care for high risk individuals

    “Mrs [name redacted] was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs”
  2. 2. insufficient resources to provide continuous care

    “The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust's”
  3. 3. inadequate service suitability for high risk individuals

    “My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.”

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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