“At the conclusion of the inquest, I indicated to the Properly Interested Persons that I…”

The coroner’s concerns

– At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. During the Inquiry, I received evidence that during the later months of his life Stephen had spent time residing mostly in the Chester / Frodsham region in Cheshire, but also in Blackpool. At the inquest his former Care-coordinator informed the court that for a number of weeks during March / April 2013 Stephen had been residing in Cheshire where concerns had been raised that his condition had deteriorated. The Care – coordinator became aware that Stephen was returning to the Blackpool area for what she understood to be a holiday period. Stephen was by that stage known to mental health services in the Blackpool area. The Blackpool Complex Care & Treatment Team had last had involvement with Stephen th on 7 March 2013 when the team had closed their service in respect of Stephen having been told he was moving back to the Chester area. Although upon his return to the Blackpool area Stephen did ring the Blackpool team prompting contact with the Care Co-ordinator in Cheshire, the Care Co-ordinator acknowledged that more information could have been provided to the Blackpool mental health professionals as regards what she knew in relation to Stephen’s mental health since the Blackpool team had last had dealings with him, even if he was only expected to be in Blackpool for a short period of time. Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:    I am concerned that there was a limited exchange of information as regards Stephen and his mental health between the mental health professionals in Cheshire and their counterparts in Blackpool. By the time that Stephen came to Blackpool for what turned out to be the final time the professionals in Blackpool did not have a detailed picture of how Stephen had presented during recent weeks in relation to his mental health. When individuals with a similar mental health history as Stephen do move from one area of the country to another there is the potential for a mental health team to find themselves with less detailed relevant information than may be the case for a similar individual who has recently been residing within the immediate area. I am concerned that the quality of exchange of information needs to be such that when mental health professionals find themselves dealing with such an individual that they have as much relevant information as possible to be able to assess the risk such a patient poses and to respond accordingly. I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any the Trust proposes to take to address these concerns.

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, 2014-0522

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0