“| read from a report received from Sol’s treating consultant psychiatrist at the…”

The coroner’s concerns

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— | read from a report received from Sol’s treating consultant psychiatrist at the Warwickshire & Coventry Partnership Trust. The consultant did not give evidence in person. In his report the consultant stated that he wrote to Sol’s GP in Cromer on 14 November 2013 requesting that the GP refer Sol to the local Mental Health Trust. When giving evidence in person the GP confirmed that the letter was not received until 9 December 2013, after Sol had died. It was not known that this was the case until the GP gave evidence before me at the Inquest. | heard at the Inquest from the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust's Access & Assessment Team. In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP, given the complex needs and history of Sol and that this should have been planned in advance. Whilst it can not be known whether had such referral been made the outcome for Sol would have been different, | am nevertheless concerned that were a_ similar circumstance to arise in the future then a preventable death might occur and there is a continuing risk that other deaths could occur which could be avoided. | was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust. This issue only arose in the light of the evidence given in person at the Inquest and was not apparent from the statements and reports provided prior to the Inquest. | would therefore record that it is accepted that in the circumstances which have arisen the Warwickshire & Coventry Partnership Trust (“the Trust’) have not had the opportunity to respond to that evidence. Had the issue been apparent from statements and reports obtained then the Trust would have been asked to attend. | therefore recognise that it is | possibie that steps may have already been taken to review the transfer of patients who are moving area. tn that event the response to this report will no doubt set out what steps have been taken. '6 | ACTION SHOULD BE TAKEN | In my opinion action should be taken to prevent future deaths and | believe you and/or | your organisation 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 Friday 15 August. |, 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, 2014-0272

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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