“The inquest heard that his family were very supportive and had attended MDT meetings…”
Dated 13 Dec 2019, from the coroner for Manchester South. Sent to 3 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 7 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 dated13 Dec 2019
- Deadline7 Feb 2020
- Published on judiciary.uk30 Dec 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 7 Feb 2020. A reply may have been sent and not yet published. |
| Tameside and Glossop Clinical Commissioning Group | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 7 Feb 2020. A reply may have been sent and not yet published. |
| Pennine Care NHS Foundation TrustNamed in the report as “Pennine Care NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 7 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. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT; 2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in- patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made; 3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge.
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, 2019-0428
- Added to Minute Book
- 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
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