“There is no formal guidance or process in place at the Trust for Consultant Psychiatrists…”
Dated 28 May 2021, from the coroner for Manchester North. 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
All responses publishedReplies were due by 23 Jul 2021.
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; a reply may have been sent and not yet published.
- Report dated28 May 2021
- Deadline23 Jul 2021
- Published on judiciary.uk2 Jun 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Pennine Care NHS Foundation Trust | Response publishedPublished on judiciary.uk in June 2021. |
The coroner’s concerns
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- (1) There is no formal guidance or process in place at the Trust for Consultant Psychiatrists to seek a second opinion in relation to diagnosis, treatment plans or whether a patient meets the criteria for detention under the Mental Health Act. The evidence was that whilst there is nothing to prohibit a Consultant requesting a second Opinion, it rarely happens in practice. (2) There is no formal guidance or process in place at the Trust for health care professionals or family members to seek a second opinion in relation to the matters set out above. (3) The court heard evidence that there is a lack of understanding on the part of in-patient Consultants as to rules around confidentiality and the nature/extent of permissible communication with family members ie: the difference between receiving information which might inform diagnosis, treatment and risk planning and discussions which involve sharing confidential health information. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 23 July 2021. |, the Area 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, 2021-0183
- 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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