“a”

The coroner’s concerns

1. a. No thorough comprehensive risk review and care plan was formulated in relation to his Diabetes monitoring and management prior to his discharge from the inpatient unit. This was not recognised before he left the ward and it was not discovered by the CMHT when they took over his care. b. No appropriate formal mental capacity assessments were made and properly recorded although this would also be relevant in managing his mental and physical conditions. c. The transfer and communication process from inpatient care to the CMHT was inadequate and incomplete. d. No appropriate contacts were made with the GP whilst the deceased was an in-patient to obtain relevant clinical information to assist in managing a serious physical health condition with potentially life threating complications and assist in the discharge planning. Nor were regular appropriate contacts made with the GP after discharge which would have highlighted the absence of medical management for a serious physical health condition. 3 e. Whilst a psychiatric inpatient and suffering from a serious physical health condition which requires monitoring and treatment it was not possible to obtain appropriate specialist advice because the deceased was not an inpatient in hospital and was not registered with a GP in that area. Consequently, there was a gap in care provision which requires local NHS primary and secondary care procedural review to resolve. f. Despite complaining of side effects, there was no apparent awareness of or consideration given to the risk and likelihood that these may be associated with his diabetes. No appropriate clinical advice was sought. g. There were a number of missed opportunities for the CMHT to assess changes in his presentation and risk profile due to a lack of appropriate communication between mental health and primary care professionals. h. There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews. h. The GMMH SUI investigation report contained several factual errors and misinterpretations. The CMHT Responsible Clinician did not provide a statement or was interviewed despite him being a crucial witness. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.

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, 2021-0329

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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