“There was a significant delay in David's referral to the Trust being triaged”

The coroner’s concerns

(1) There was a significant delay in David's referral to the Trust being triaged. When the triage did take place, I was told in evidence that David's referral was not triaged well, which had numerous implications for David's treatment later on. I was told that the Trust now provides more support for staff triaging referrals; however, this did not provide sufficient reassurance that the risks have been addressed. I am also mindful of Prevention of Future Death report (2026-0023), written by me on 12 January 2026, which contained a similar concern about the process for triaging referrals (albeit in relation to a different team within the Trust). This indicates that this may not be a localised, team specific, issue in terms of the triaging of referrals. (2) David's Dialog+ assessment (an assessment tool, which includes questions to assess risk) was not undertaken by a clinician. I was told in evidence that, given the complexities of David's case, his Dialog+ assessment 'would have benefitted' from assessment by a clinician and that he should have been seen by a qualified clinician at that appointment. I heard evidence that the Band 4 member of staff who undertook the assessment was content with their assessment and the plan that was formulated as a result of it. However, that plan did not include referral to be seen and assessed by a qualified clinician, whereas the evidence I heard was that there was an expectation that David should have been referred to a qualified clinician. While I heard and accepted the evidence that a patient in a similar situation to David would now be able to access the MHT+ team directly, the issue here is one of potential training concerns where non-clinical decision makers are potentially over-confident or may not fully understand the nature and effect of the decisions they are required to make. I was not reassured that this matter has been addressed. (3) It was accepted in evidence that there was a delay in David being seen by a qualified clinician. It was further accepted that there were numerous 'missed opportunities' for David to be referred to, or seen / spoken to by, a qualified clinician. Again, I accept that a similar patient now, would be able to access the MHT+ team directly. However, the concern remains that there is potentially a wider training issue that could lead to continued 'missed opportunity' exposing future patients to continued risks. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 June 2026. I, the coroner, may extend the period.

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, 2026-0222

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