“Mr Ashley’s Care and Treatment Plan was not updated when his mental health deteriorated”
Dated 16 Mar 2020, from the coroner for West Sussex. 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 11 May 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 dated16 Mar 2020
- Deadline11 May 2020
- Published on judiciary.uk8 Apr 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sussex Partnership NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 11 May 2020. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. Mr Ashley’s Care and Treatment Plan was not updated when his mental health deteriorated. 2. Staff were not recording interactions with Mr Ashley in the CareNotes system and often emails were not copied into these notes. Therefore there was a lack of compilation of key information relating to Mr Ashley. 3. There was no system in place for Lead Practioners to be notified of an important entry in a patient’s CareNotes where action was required. 4. Mr Ashley had not been seen by a Psychiatrist for over a year and there was no evidence that the deterioration of his mental health (and his non compliance with his medication) had been reviewed by the professionals weekly team meetings. 5. The Inquest identified that there was a discrepanciy in the Trust’s own Policies as to when a Risk Assesment should be reviewed. 6. Save for the duty scheme there appears to be no procedure in place for another practictioner to cover a Lead Practictioner’s case load or any formal handover when they are on leave. Therefore there was no single person who has uptodate knowledge of a patient who may be in need or whose mental health was deteriorating. 7. The Inquest heard evidence that the Liasion Mental Health Team at the Hosptial did not make use of patient’s Care and Support Plans or Central Risk Assessment. 8. The was no clear procedure for GPs to be updated by Care Coordinators with details of a patient’s current treatment plan if it had been changed. This was particulary important where there was no regular assessments by a Psychiatrist who would in the normal course of events be providing such updates.
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, 2020-0071
- 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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