“The first concern is the "unacceptably long wait" for referrals, assessments and…”

The coroner’s concerns

- (1) The first concern is the "unacceptably long wait" for referrals, assessments and diagnoses of ASD and ADHD. The court was told that demand is continuing to outstrip the services ability to cope; services are outsourced to private providers but there are still unacceptable delays. This impacts the provision of care, the provision of appropriate medication, providing the individuals with insight and understanding of their own presentations and the provision of professional support. In Kallum's case this contributed to the factors that caused his death. I am therefore raising this concern with the Minister for the DHSC and the WLNHS Trust 5 (2) The second concern is that the court was told that the "crisis team" gate-keep referrals into their service, notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments. The care planning in Kallum's case advised him to contact the single point of access (who had rejected referral back to the crisis team in the weeks preceeding the death), to present to ED (which he did but was discharged home to remain under the community team). The pathways essentially failed as the crisis team still was able to reject the referral, thus effectively closing down an avenue for ongoing close care and communication as the crisis presentation continued. The Trust's internal report concluded that Kallum should have been assessed in person and probably should have been accepted back by the crisis team, but in court this conclusion was contested by the service manager. His evidence was that the crisis team was not appropriate for Kallum and the community team should continue the care. This re-emphasied the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution. The situation appears not to have changed in the 12 months following this death. There appears to be no route to access the "half way house" provisions of care unless via the crisis team and so these were not offered or discussed with Kallum or his family who were trying to care for him. I am therefore raising this concern with the WLNHS Trust

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, 2026-0061

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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