Safoora Alam
6 Dec 2019 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. inconsistent sharing of documentation and case notes between agencies
“Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the agencies involved.”
2. lack of joint Mental Health Trust and social care packages for patients with complex physical health needs
“There was a lack of a joint Mental Health Trust and social care packages for patients with complex physical health needs or opportunities to convene multi- agency meetings”
3. lack of information gathering prior to the visit to see Ms Alam by Social workers
“There was a lack of information gathering prior to the visit to see Ms [name redacted] by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took place.”
4. slow and cumbersome urgent referral process via safeguarding team and GP
“The Local authority housing officers did recognise the escalating risk in her mental health state but the mechanism for urgent referral via the safeguarding team and GP was a slow and cumbersome process which didn't work.”