“(brief summary of matters of concern) Evidence was heard regarding the operation of a…”

The coroner’s concerns

(brief summary of matters of concern) Evidence was heard regarding the operation of a triage for patients who may be experiencing a mental health crisis. A practice had developed of bypassing specialist mental health assessment by means of telephone workers making their own judgments about the level of risk a person presents to themselves and others, and a judgment about whether or not they require urgent mental health assessment and / or treatment, based on a very limited criteria. This had the result of only a very small proportion of potentially unwell patients being considered by a person with qualifications to assess and treat mental health. This was a culture and practice which stood in conflict with the procedure the Trust had in writing for the role of the telephone workers. I was also concerned regarding the apparent lack of involvement of a care co-ordinator at the Trust, given that a variety of agencies and persons were involved in seeking to assist and treat Mr Nottle. Lastly, I was concerned that there was evidence of a lack of clarity of thinking within the multi-disciplinary team in relation to the decision to discharge Mr Nottle and the apparent recalcitrance of the multi-disciplinary team in relation to repeated re-referrals into the service. This may be linked with the lack of care co-ordination or may be a cultural or practice issue within the operation of the multi-disciplinary team. It is requested that consideration be given to:1. 2. 3. 6 Clarifying the role of telephone workers and the steps necessary to ensure that the government guidance regarding access to mental health services is followed so far as is possible within the available resources; Steps to ensure that, for individuals with complex mental health needs involving a range of providers, there is co-ordination of care to ensure that appropriate care is in place and, where necessary, a consistent approach is taken to patients by different organisations or teams working with the patient; and Review of the multi-disciplinary team’s decision-making process in light of the issues identified by Mr Nottle’s circumstances.

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, 2022-0189

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