“A more co-ordinated approach from the mental health services is required when a user is…”
Dated 16 Jun 2017, from the coroner for Liverpool and Wirral. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 11 Aug 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated16 Jun 2017
- Deadline11 Aug 2017
- Published on judiciary.uk11 Aug 2017
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Mersey Care NHS Foundation TrustNamed in the report as “Mersey Care NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 11 Aug 2017. A reply may have been sent and not yet published. |
| Chester Hospital NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 11 Aug 2017. A reply may have been sent and not yet published. |
The coroner’s concerns
– A more co-ordinated approach from the mental health services is required when a user is being transferred from one NHS Trust to another. In this case if the user had still been on a Care Programme Approach there would have been a direct referral from service to service rather than through the GP but because he was taken off the programme the referral was made through the GP. This has delayed the intervention and the prevented effective information exchange on a user who was already subject to secondary care services. In effect this resulted in the user having no intervention for a number of months and entering the mental health system afresh when in fact the care should have been a seamless continuation. The Court would like you the Current Transfer / Referral Policy.
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, 2017-0196
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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