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recurance

Michael Hindes

20 Oct 2023 · Coroner Mary Hassell · Inner North London

The coroner's concerns

  1. 1. lack of follow up by community mental health team

    “When [the deceased] was taken to St George's Hospital, he explained that he had been back and forth from the railway station, each”
  2. 2. insufficient family involvement in mental health care

    “Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient's care”
  3. 3. lack of persuasion to involve family

    “the assessing nurse did not in any way try to persuade [the deceased] to allow her to do this”

Responses

2023-0521-Response-from-South-West-London-and-St-Georges-Mental-Health.pdf ↗· South West London and St George's Mental Health NHS Trust

Stated action · March 2024

“we will take the opportunity to raise awareness within the Trust via a specific newsletter article issued to Trust staff (known as our Monthly Learning Bulletin) to remind and promote how and when to best ensure there are meaningful conversations with patients around sharing information with families. This will focus on the Triangle of Care approach and provide clarity around the delicate balance between encouraging patients whilst respecting their wishes and ensuring this is clearly documented.”
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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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