“, — (1) Mr Jones was initially referred to the Crisis Team because his GP believed that…”

The coroner’s concerns

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, — (1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community. (2) When Mr Jones was in due course discharged from the Crisis Team’s care it was approximately a week before his GP was notified of that discharge. That notification was received by fax. (3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team. (4) in evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it. (5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protacois for the sort of communication envisaged by Mr Jones’ GP.

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, 2016-0327

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