“On 13/07/22 Dr Ellson's GP needed to arrange an urgent mental health review as Dr Ellson…”
Dated 20 Dec 2022, from the coroner for Birmingham and Solihull. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 14 Feb 2023. A reply may have been sent and not yet published.
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.
- Report dated20 Dec 2022
- Deadline14 Feb 2023
- Published on judiciary.uk20 Dec 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Hereford and Worcester Health and Care NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Feb 2023. A reply may have been sent and not yet published. |
| NHS Herefordshire and Worcestershire Integrated Care BoardNamed in the report as “Hereford and Worcestershire ICB” | Response publishedPublished on judiciary.uk in December 2022. |
The coroner’s concerns
- 1. On 13/07/22 Dr Ellson's GP needed to arrange an urgent mental health review as Dr Ellson had presented with suicidal ideation. The GP had significant difficulties trying to contact the Mental health team with messages giving incorrect numbers. My concern is that the system for GPs to contact mental health teams for urgent reviews is not clear nor safe. 2. Once contact had been made and a request was made for Dr Ellson to be assessed by the mental health team, the system in place is for the patient to call the mental health practitioner. My concern is that the patient is likely to be in crisis, which is why a referral is being made, and the burden should not be put on them to make the call. 3. The GP caring for Dr Ellson on 13/07/22 was unaware that she could make a request for a psychiatric review of the patient. The inquest heard how this was not well known by local GPs. My concern is that GPs should be fully aware how to request an urgent psychiatric review for patients.
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, 2022-0406
- 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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