“CONCERN 1 On The 6th July 2016 a nurse at the Trust contacted Mr Cardwell to find out why…”

The coroner’s concerns

– CONCERN 1 On The 6th July 2016 a nurse at the Trust contacted Mr Cardwell to find out why he had not attended his appointment with the Psychiatrist that day. Mr Cardwell told the nurse that he had been unable to attend the appointment because he had no petrol. He also advised that he had no phone credit and had therefore been unable to contact them. Mr Cardwell reported that his ex-partner had stolen his bankcard and that all the money had gone from his account. The nurse advised that this information would be passed to the MDT for their consideration the following day. Mr Cardwell wanted another appointment but he said it would have to be a home visit. Whilst Mr Cardwell was discussed at the MDT meeting on the 7th July and discharged, I found on the evidence that the message explaining his nonattendance and requesting a further appointment was not relayed to the MDT. Had that message been relayed to the MDT, I found that Mr Cardwell would have been offered a further appointment and would not have been discharged at that time. This failure in communication is a matter of concern. I am concerned about the process by which messages are relayed from service users to the MDT team. The nurse explained that the information was passed on to be taken up by the Duty Worker and it should then have been reported to the team. The nurse also recorded the contact in Mr Cardwell’s clinical record but these were not looked at during the course of the MDT meeting. CONCERN 2 On the 6th August 2016 Mr Cardwell was seen in hospital by a member of the liaison team following a significant overdose. He was later discharged from hospital and he queried with the HTT on the 9th August 2016 (on attending West Strand House in person) whether he was due a follow-up with the HTT. Mr Cardwell was told that the MDT would be asked the following day and that someone would contact him from the team to let him know. I found that the message was - on this occasion - relayed by the Duty Practitioner to the MDT on the 10th August 2016. However, the MDT did not discuss Mr Cardwell and nothing was recorded about him. No-one contacted Mr Cardwell back to advise him as to whether or not he would have an appointment with the HTT. I heard evidence that the MDT meeting could be disorganised. I am concerned that Mr Cardwell was not considered by the team, despite the message being handed over to them. I am also concerned about a lack of record keeping during the MDT. Even where patients are discussed, the notes appear to be very brief.

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, 2017-0203

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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