“The coroner found that there were two failures in medical care, namely 1”

The coroner’s concerns

The coroner found that there were two failures in medical care, namely 1. The failure to contact at the Mental Health Act assessment in April 2. The failure to take and consider the history of before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to , about which there was an inadequate plan communicated to the GP. These would have amounted to neglect, had it not been for the fact that there was no causative link with the death. CORONER’S MATTERS OF CONCERN are as follows. – 1. The fact that the deceased was under a restriction order not to contact his ex-wife was cited as a reason that no contact was made by the professionals conducting the MHA assessment. This may raise some process issues but would not seem to be an obstacle to securing corroborative evidence and insight into possible psychosis, especially noting the deceased gave no indication that he opposed such a communication. 2. The witness evidence heard and records consulted give the impression that those professionals involved in his care had discounted his symptoms as non-psychotic, without adequate investigation, underestimated his suicidality and not addressed the concerns of the GP who referred him about his management, and to whom his care passed without any psychiatric follow up or support. 3. Neither failure was recognised or investigated by the Root Cause Analysis which was described as Level 2 Comprehensive and concluded that there were no problems in health care. The court regarded the RCA investigation as unreliable. That causes some concern as to whether the Trust is able to identify care problems in future.

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, 2020-0134

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0