Vincenzo Lippolis
26 Oct 2022 · Coroner Paul Cooper · Lincolnshire
The coroner's concerns
1. lack of mental health unit admission
“An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future”
2. opportunity loss leading to preventable death
“Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted”
3. telephone call instead of face-to-face observation
“Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken”