Mohammed Choudhury
6 Jan 2026 · Coroner Emma Whitting · Bedfordshire and Luton
The coroner's concerns
1. violent behaviour due to untreated paranoid schizophrenia
“The risks identified in respect of [REDACTED] on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider”
2. absence of multidisciplinary team plan
“There was no MDT plan to address the significant development of [REDACTED] non- concordance with his anti-psychotic depot medication from mid-September 2022”
3. withdrawal of medication support without GP verification
“Despite knowing that [REDACTED]lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any checks made with his GP as to whether he was remaining complaint with this medication (which he was not)”