“That the HHT is not sufficiently funded to allow continuity of care and named designated…”
Dated 15 Apr 2014, from the coroner for Inner West London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 10 Jun 2014. A reply may have been sent and not yet published.
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.
- Report dated15 Apr 2014
- Deadline10 Jun 2014
- Published on judiciary.uk15 Apr 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Clinical Commissioning Group for Wandsworth | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| South West London and St George's Mental Health NHS TrustNamed in the report as “South Wet London and St George’s Mental Health NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
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) That the HHT is not sufficiently funded to allow continuity of care and named designated workers. (2)That discharge from the HTT is required before referral to psychology can be made, leaving patients without ongoing support in the interim. (3) That liaison psychiatry does not record pertinent information such as GP recommends section, this denying those coming after the benefit of the GP’s professional opinion. (4) That such an extremely psychiatrically unwell patient does not have the benefit of assessment from a health care professional qualified to make recommendations for section at first instance, despite explicit referral for the same from the doctor who knows him best. (5) That secondary care services both the HTT and Liaison Psychiatry appear under to be under-resourced especially in terms of medically qualified personnel, and that this apparent under-resource impacts on the ability of these services to make accurate assessments of patients. (6) That The SUI report missed all matters in issue in this 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, 2014-0172
- 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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