“At the time of discharge from Holywell Hospital on the 30" January 2017 Mr”

The coroner’s concerns

This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.

— 1. At the time of discharge from Holywell Hospital on the 30" January 2017 Mr. Gould had been referred to the community mental health team for a 7 day review and had been given an appointment on the 2™ February 2017. There is no evidence in the Trust’s records that the time, date and location of this appointment was given to Conall or his parents. 2. The evidence AEE consuitant Psychiatrist, who saw Conall and his father on the 30" January 2017 was that he anticipated that the discharge nurse would tell Conall and his mother or father, as his carers, the date of his review at the point of discharge as this is the usual practice. 3. Mr. Gould, Conall’s father, gave evidence that not only were he and his wife not told verbally of the appointment nor were they given any written information about it: on a previous discharge from an inpatient stay at another — had been given a letter setting out the appointment arrangements for his son following discharge. Conall was 21 at the time of his discharge on the 30" January and his parents had taken a very active role in his care. If they had been aware of the appointment they would have made every effort to secure Conall’s attendance, as it was, believing there to be no plan for follow up, they did not prevent him from travelling to Birmingham for a period of rest with relatives (during which time he took the fatal overdose of MDMA). 4, The evidence 0 1° conducted the RCA was that the Trust does not have a protocol or policy stipulating the arrangements for notifying services users and their carers of follow up arrangements on discharge and current practice does not require written confirmation of follow up arrangements to be given to the service user or their carers. 5. The system currently creates a risk that services users and their carers will not be aware of follow up appointments and therefore may not attend giving rise to a danger that opportunities to review the service user’s condition and treatment will be lost.

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, 2017-0458

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0