William Grieve
19 Mar 2025 · Coroner Emma Serrano · Staffordshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate risk assessment
“Evidence emerged during the inquest that Mr [name redacted] was under the care of Stoke Talking Therapies, and had also presented at the Stoke crisis Evolution Team. Both had conducted suicide risk assessments of Mr [name redacted].”
2. information siloing
“Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system. Stoke Talking Therapies used IAPTUS and Crisis resolution used Lorenzo. There was no way for either team to see the others electronic notes.”
3. staff training gaps
“It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this and there were no plans to address this. The concern being that staff training needs are not being addressed.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.”
This report
“Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system.”