“During the 2½ years in which Charlotte’s mental health care was provided by the Trust…”

The coroner’s concerns

– (1) During the 2½ years in which Charlotte’s mental health care was provided by the Trust, she had total of 8 different care coordinators. Furthermore, in those 2½ years there was a 5 month period when Charlotte had no appointed care coordinator at all. The care coordinator role is particularly important for a patient with such a complex case history as Charlotte. I heard evidence that at the time of these events, the Trust had been experiencing an unprecedented level of instability, with many staff who might have been expected to fulfil care coordinator roles going off sick or even leaving the service. The witness who had conducted the Trust’s own internal investigation into these events gave evidence that one of the major reasons for this instability was that staff were unable to cope with ever-increasing workloads. The Trust’s Community Services manager for the Worcestershire Neighbourhood Teams appeared to corroborate this in his evidence, confirming that whilst national guidelines recommend a maximum of 30 patients per care coordinator, at the time of these events the Trust’s care coordinators had around 100 patients each. Whilst he was able to provide some reassurance that a recent recruitment drive has reduced individual care coordinator caseloads to around 25 patients, he was unable to explain how individual caseloads had been able to reach the levels they did at the time of these events, and was unable to give accurate figures as to current levels of staff sickness/absence. I am concerned that the Trust is unable to understand fully how the care coordinator system failed at the time of these events, and that it is therefore not in a position to guard against a repeat of these circumstances in the future. (2) The erroneous decision to pause Charlotte’s referral to the Priory Hospital for specialist treatment for Body Dysmorphic Disorder was taken by a senior clinician acting on her own, despite a Multi-Disciplinary Team meeting having decided that the referral was appropriate. When asked about how the senior clinician could have overridden the MDT decision, the Trust’s Community Services manager for the Worcestershire Neighbourhood Teams told the inquest that he could not say whether the senior clinician was not aware of the correct decision-making procedure, or whether she was, but chose instead to ignore it. When asked whether the same issue could arise in future, he told the inquest that he himself would be in a position to prevent the senior clinician making the wrong decision, but could not guarantee that he would be made aware of the issue so as to be able to do so. I am concerned that the Trust has not properly established how the senior clinician was able to override the MDT decision, and does not have a sufficiently robust system in place to ensure that MDT decisions cannot be overridden in this way in future.

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, 2023-0089

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