“Mrs Beasley was seen at home following a call to the mental health crisis team and…”

The coroner’s concerns

– (1) Mrs Beasley was seen at home following a call to the mental health crisis team and required a full V4 mental health assessment that did not take place and instead an SBAR review was completed, and the nurse did not scrutinise the medications and medication changes that had been previously made and made errors about the doses. Mrs Beasley was informed she was discharged back to her GP, but no actions were sent by the mental health Trust to the GP. (2) Following this Mrs Beasley contacted crisis mental health explaining that she had vital information that she had not shared following a visit by a psychiatric nurse at her home. Mrs Beasley was not asked what the information was. Mrs Beasley contacted the crisis team again a few days later repeating that she had not shared information and again was not asked what the information was and was not given an appointment. Mrs Beasley’s telephone contacts were noted in her medical record with no details recorded as to what the additional information Mrs Beasley wanted to share. Mrs Beasley did not receive the appropriate psychiatric assessment following her contact with the crisis team. (3) Mrs Beasley was conveyed to hospital having taken an overdose of medication and was reviewed by the Trust mental health liaison team. Review of the mental health Trust medical records would have shown that Mrs Beasley had an SBAR review rather than a V4 mental health assessment. This should have alerted staff to the fact that an urgent assessment was required when Mrs Beasley attended mental health liaison following an overdose of her medication. This did not happen. (4) Mrs Beasley had been requesting an urgent appoint and responded immediately to a letter from the Trust informing her she needed an urgent psychiatric appointment. When Mrs Beasley contacted the crisis team, she was again informed incorrectly that she had recently had a V4 psychiatric assessment and did not require an urgent appointment. 2 The crisis team were not communicating effectively either with Mrs Beasley, her GP or internally within their own team. (5) Multiple experienced members of the mental health teams had contact with Mrs Beasley between January and March and did not make detailed entries into the medical or ask questions of Mrs Beasley about what additional information she had to provide about her risks of harm and suicidal ideation, review of her medication given her deteriorating mental health and calls to the crisis team disclosing increasing suicidal thoughts and ideation accompanied by acts and plans. There was a lack of professional curiosity and poor record keeping and rationale for decision-making.

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, 2025-0250

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