“Training for Doctors and other medical staff in relation to referring patients for…”
Dated 8 Apr 2014, from the coroner for Wiltshire and Swindon. 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 3 Jun 2014.
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 dated8 Apr 2014
- Deadline3 Jun 2014
- Published on judiciary.uk8 Apr 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Great Western Hospitals NHS Foundation TrustNamed in the report as “The Great Western Hospital” | Response publishedPublished on judiciary.uk in July 2014. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 1. Training for Doctors and other medical staff in relation to referring patients for assessment both within the hospital and externally following discharge. — During the course of the Inquest EN ove evidence and it was quite clear that he did not have a clear understanding of the referral procedure to involve professionals from the Avon and Wiltshire Mental Health Partnership. He believed his telephone conversation with the Swindon Intensive Services with CPN oul: result in the outreach team assessing Andrew in the community. He thought that a telephone call alone would be sufficient in that respect to engage the Mental Healthcare professionals. The importance of a clear and effective communication pathway following recognised and agreed practices and procedures cannot be ignored and | am concerned following the evidence | heard there were knowledge gaps as regards practice and procedures to be followed when engaging Mental Health Partnership personnel. | would be grateful if you could please review the appropriateness and the effectiveness of training in this respect not only for current GWH personnel but also how effective training in this area can be given to personnel in the future. Whilst | was satisfied that this did not contribute to Andrew's death in this instance my concern is that an issue could arise in the future whereby that may not be the case.
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, 2014-0163
- 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
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