“a@re as follows”

The coroner’s concerns

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a@re as follows. — The South London and Maundsley NHS Foundation Trust (‘The Trust’) completed it’s own Mental Health Investigation Re England Serious Incident Framework. The investigation was conducted oo Consultant Liaison Psychiatrist, St Thomas’ Hospital and Team Leader of Lewisham PMIC Treatment Service. The Report acknowledges that Edward Lundy was known to the Trust since 15"" July 2016 being reported initially to Lambeth Assessment and Liaison Team and then to the Lambeth Living Well Network Hub where Edward was seen twice on 10" and 18" August 2016. Lambeth Hub contacted Wandsworth IAPT with a view to requesting that psychological therapy be re-started and an appointment was made for 24" August 2016. The Trusts own findings identified a number of issues and a number of proposed actions. 1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with Old Municipal Buildings, Corporation Street, Taunton, Somerset, TA1 4AQ Tel 01823 359271 | Fax 01823 355060 provider organisations involved with an oversight report to be produced. 2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the tisks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaisons Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings. 3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission. There has been no evidence produced as to compliance with the recommended actions. There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts. That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure. Old Municipal Buildings, Corporation Street, Taunton, Somerset, TAI 4AQ Tel 01823 359271 | Fax 01823 355060 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.

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, 2018-0087

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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