“The inquest heard evidence that whilst initial appointments with his GP were face to face…”
Dated 10 Jun 2025, from the coroner for Manchester South. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 5 Aug 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated10 Jun 2025
- Deadline5 Aug 2025
- Published on judiciary.uk18 Jun 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Greater Manchester Integrated Care BoardNamed in the report as “Greater Manchester Integrated Care Board” | Response publishedPublished on judiciary.uk in June 2025. |
The coroner’s concerns
– The inquest heard evidence that whilst initial appointments with his GP were face to face they became telephone appointments even when he indicated that his mental health was not improving. In addition there was no attempt to gain input from his family into the reality of the situation in relation to his mental health. The evidence given by his family at the inquest was that they could have provided valuable information into the 1 clinical assessment but did not feel they had the opportunity to provide this information. The consequence of these two factors was that his risk was not recognised. On the evidence before the inquest there is no guidance for the use of telephone appointments in preference to face to face for GPs across GM and no mechanism for family input in these situations.
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, 2025-0290
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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