“Alex Alfred Robinson was admitted to the Royal Shrewsbury Hospital (RSH) on the 8…”

The coroner’s concerns

Alex Alfred Robinson was admitted to the Royal Shrewsbury Hospital (RSH) on the 8 September 2025 when he was seen in the same day emergency centre by the consultant on call. That consultant has made a statement and in paragraph 12 sets out his plan including “arrange review by mental health liaison team (MHLT). Following discussion, MHLT provided advice and a leaflet to be given to the patient as they are not available on site out of hours to review the patient physically”. In a later statement (in paragraph 3) the consultant further states “I was not present at that moment when the resident doctor discussed with MHLT service, but she informed me that MHLT informed her they will not be available to see Mr Robinson at that time”. 2 Subsequent inquiry with MHLT stated clearly that Midlands Partnership Foundation Trust (MPFT) Mental Health Liaison Team at RSH is a 24/7 service, they had the usual night cover of cover of two staff on the 8/9 September 2025 and that no formal referral was ever received. This conflicting information represents a lost opportunity for Alex to have received appropriate care from MPFT which may have prevented Alex from killing himself on the 10 September 2025, but this cannot be known. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] 1. Partner of Alex 2. The Chief Executive, Midlands Partnership NHS Foundation Trust (MPFT) I also have a duty to send a copy of the report to the Chief Coroner. 9 You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE 3

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

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