“That no-one appeared to have looked at his mental health except to note that he was…”
Dated 12 Dec 2019, from the coroner for Norfolk. Sent to 1 organisation or person.
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 6 Feb 2020. 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 dated12 Dec 2019
- Deadline6 Feb 2020
- Published on judiciary.uk30 Dec 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Norfolk and Suffolk NHS Foundation TrustNamed in the report as “Norfolk & Suffolk NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Feb 2020. A reply may have been sent and not yet published. |
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) That no-one appeared to have looked at his mental health except to note that he was alcohol dependant. This was an escalating presentation from someone who had no previous contact with the services. (2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't. (3) The various teams within the Trust seem to be unaware of each other’s referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP’s opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol.
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, 2019-0423
- 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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