“Mary was discharged from the Abraham Cowley Unit without a discharge planning meeting…”

The coroner’s concerns

– 1. Mary was discharged from the Abraham Cowley Unit without a discharge planning meeting taking place in circumstances where there was no confirmation that she was eligible for housing provision and with no plan was to what would happen after the Travel Lodge placement ended. There is no policy in place which prevents a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit. 2. Mary was not subject to a medical review from the 28th March 2018 to the 26th May 2018. There is no policy in place which mandates when or if a patient should be subject to face to face review by a consultant psychiatrist after discharge from the acute unit. 3. No formal risk assessment was undertaken of Mary and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit. 4. The informal risk assessments undertaken in the Abraham Cowley Unit prior to her discharge failed to place any weight on the impact on Mary of a discharge with an inchoate plan for her housing and arrived at an incorrect assessment of her risk. The risk assessments were not sufficiently rigorous and evidence based. 5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA ( “ Care Programme Approach”) was not followed. 6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed. 7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with medication.

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, 2021-0117

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