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recurance

Roy Morris

29 Mar 2021 · Coroner Crispin Butler · Buckinghamshire

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. lack of detailed care plan on discharge

    “The application of the CPA policy for patients such as [the deceased] so that they will have a detailed care plan with which they can engage and which informs the family, the care coordinator and the community team on discharge from the inpatient setting”

Linked reports

Repeats an earlier warningLewis Colgan9 May 2018 · 2 years 11 months earlier
Closely relatedConfidence 0.80 · moderate

Earlier report

“There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these.”
Original on judiciary.uk ↗

This report

“The application of the CPA policy for patients such as [the deceased] so that they will have a detailed care plan with which they can engage and which informs the family, the care coordinator and the community team on discharge from the inpatient setting.”
Full chain: Overdue CPA meetings and missing discharge care plans

Responses

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted.pdf ↗· Oxford Health NHS Foundation Trust

Stated action · early June 2021

“To focus on the role of the Care Coordinator: the expectations of the role and the interventions and engagement required in discharge planning in line with our CPA policy.”
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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error

Roy Morris · Recurance