“Mr Sweet presented in equivocal and contradictory fashion”

The coroner’s concerns

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Mr Sweet presented in equivocal and contradictory fashion. Accordingly, he was very difficult to assess and it was equally difficult for clinicians to form a view of the likely risk he posed to himself. | was concerned, however, that the very day after a Consultant Psychiatrist contemplated informal admission into hospital, a nurse from the HTT felt able to refer Mr Sweet to the Community Mental Health team where he was not seen for a month. | wondered if it may be appropriate to reflect on how to deal with patients who present in an inconsistent manner. In particular, | questioned whether it was appropriate simply to presume the best case scenario. | was further concerned whether or not it was appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions. There appeared to be obvious inconsistencies first in the concern of fiiand the decision the very next day to discharge Mr Sweet from the caseload of the HTT and secondly, in the decision of See refer to CMHT yet EEE discharging Mr Sweet from caseload after a first assessment. Mr Sweet's case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating. | recognise this is a difficult issue. | wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm. Furthermore, | feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition. | recognise there will be an obvious need to respect the rules on confidentiality. | raise also whether there should be training to i entries j tes and records are consistent. By way of illustration, where and decide to discharge Mr Sweet from their respective caseloads, they should justify those decisions in light of s earlier concern that Mr Sweet may need an informal admission into hospital. incomplete. In particular, neither nor had been formally interviewed as part of the review process. You may feel that there would be merit in getting the respective clinicians from the relevant departments (Hospital Liaison, HTT and CMHT) together to see if there are any lessons to be learned. A final matter that came out of the —_ was that the Serious Incident Report was _

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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