Simon Alliston
19 Jan 2015 · Coroner Thomas Osborne · Bedfordshire & Luton
The coroner's concerns
1. discharge without handover to community team
“in that [the deceased] was discharged from the Crisis Team on the 23rd June 2014 without any handover to the Community Team. The Community Team in evidence informed me that in their opinion [the deceased] still required enhanced support. No one was able to give me any reason for the discharge.”
2. discharge without formal handover
“(1) That a patient with a long mental health history was discharged without a formal hand over.”
3. discharge against clinical recommendation
“(2) That he was discharged when the Community Team still considered that he needed support.”
4. lack of documented discharge rationale
“(3) That the reason for discharge was never recorded.”
5. absence of serious incident investigation
“(4) That following the death of [the deceased] there was no formal Serious Incident Investigation”