“S are as follows: Those in need of the TTT service and support may feel discouraged from…”

The coroner’s concerns

S are as follows: Those in need of the TTT service and support may feel discouraged from engaging with the service and be left at risk in the community if, when repeated cancellations occur, they are spoken to only by an office administrator, who is not in any position to enquire about their mental health or make any assessment of their current condition. Indeed , the Clinical Lead for the Time to Talk service in the North Area, of gave evidence at Gemma Azhar’s inquest and informed me that in her view, the service “did not get it right”. She stated that given that the TTT service had cancelled Ms Azhar‘s apppointment twice, it would have been preferable if there had been attempts made to find her an alternative therapist on 30 September 2019 and, if none was available, for a duty worker to have spoken to Gemma Azhar before she was discharged from the service in order to understand: the reasons for her now declining a third appointment; her current mental state and, if appropriate, seek to engage her and assess her present risk. informed me that it was now the ‘formal’ position that this should happen after a second cancellation by the service. However, it is a matter of concern to me that staff working in the North area (Horsham, Crawley and Mid Sussex) have only been notified of this ‘formal position’ by an email sent in or around December 2019. This procedure is not part of any written policy or protocol or induction training and therefore new staff in the North area would only learn of the procedure by word of mouth. Furthermore, was not aware whether or not a similar instruction had been given to the Sussex Community NHS Foundation Trust’s staff working for the TTT service in other areas. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by April 07, 2020. I, the coroner, may extend the period.

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, 2020-0026

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