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recurance

Noah Lomax

24 May 2019 · Coroner Angharad Davies · South Yorkshire (West)

The coroner's concerns

  1. 1. inadequate CAMHS referral form

    “CAMHS Clinical Lead, said that there had not been any other problems with the form with GP's not completing them sufficiently. I am not sure how is able to be so confident about this.”
  2. 2. current referral form does not capture required information

    “The Trust's investigation report stated that the evidence”
  3. 3. reliance on GP training instead of form redesign

    “I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form.”
  4. 4. delayed care due to insufficient referral information

    “I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care.”

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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