“Failures in Care Planning: specifically, a failure to appropriately up-date and document…”

The coroner’s concerns

(a) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Darren’s Care Plan consistent with Trust policy. The last up-date to his Care Plan was 12 days prior to discharge. (b) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy with evidence of the ‘cutting and pasting’ of entries including Darren’s initial 72-hour care plan containing details of another patient entirely. (c) Failures in Risk Assessments: specifically, failures to appropriately update and document matters relating to Darren’s risk assessment consistent with Trust policy. Relevant passive and active risk factors were not formally reflected in his documented risk assessments. Evidence from his Responsible Consultant Psychiatrist and the discharging Psychiatrist confirmed that, had they been aware of a disclosure made by Darren to his key worker/nurse prior to discharge, the Section 2 detention would not have been rescinded, he would not have been discharged on the 17th October and, accordingly, it is likely that he would not have taken his own life the following day. (d) Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. This failure (resulting from significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death - and in respect of which no DATIX was ever raised) was a feature that contributed to the serious failure in discharge planning in this case. (e) Failures in Communication including a failure to appropriately liaise with the deceased’s Family and, specifically, Darren’s mother to establish the suitability and safety of a discharge to her address not least in the context of Darren’s disclosure that discharge to his mother’s home might “make him feel worse” at a point in time that he later acknowledged “would be overwhelming” for him. (f) Failures in Discharge Planning and Execution: specifically, in addition to the features above, a failure to actively reconsider the safety of the discharge on the afternoon of the 17th October in light of the disclosure from Darren’s mother that she would not, as had been previously indicated, be able to either collect Darren from the Ward or be at her home when he was discharged. There was no evidence of how, in fact, Darren even left the Unit. It is likely that the chaotic and unsupported nature of Darren’s discharge from Gosfield Ward, also in breach of Trust policy, more than minimally contributed to his death some 18 hours after discharge.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0144

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0