“The approach of the Crisis Resolution Home Treatment Team of considering their role to be…”

The coroner’s concerns

(1) The approach of the Crisis Resolution Home Treatment Team of considering their role to be limited to avoiding the need for patients to receive inpatient treatment. The primary role of any medical professional ought to be the protection of life, but within the written and oral evidence from the CRHTT the focus was on prevention of hospital admission alone. (2) This inquest was one of a number of inquests I have conducted where staff members from Nottinghamshire Healthcare NHS Foundation Trust have placed great reliance upon their interpretation of a patient’s intention and / or a patient’s denial of ongoing suicidal intention. This is so even where, as was the case for Mr Barton, there is a clear and established pattern of fluctuating and contradictory intentions and desires towards suicide. (3) The quality of the Trust’s own investigation into the circumstances of Mr Barton’s death. It failed to identify themes of concern. It included many false and inaccurate statements, failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records. It caused distress to the family and did not reassure me that the Trust had taken an appropriate response to the concerning facts of this case.

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, 2021-0338

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