“That the GP summary did not contain pertinent psychiatric history that would have…”
Dated 26 Apr 2023, from the coroner for Inner West London. Sent to 3 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 21 Jun 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 dated26 Apr 2023
- Deadline21 Jun 2023
- Published on judiciary.uk3 May 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| St George's University Hospitals NHS Foundation TrustNamed in the report as “St Georges University Hospital NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 21 Jun 2023. A reply may have been sent and not yet published. |
| The Roehampton Surgery | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 21 Jun 2023. A reply may have been sent and not yet published. |
| NHS South West London Integrated Care Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 21 Jun 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
1. That the GP summary did not contain pertinent psychiatric history that would have assisted the hospital clinicians to identify Mrs Leaver's depression and specifically her suicidality. 2, That doctors at SGH do not take a reasonable psychiatric history as part of their clerking and thus fail to make a proper holistic assessment of the patient and potentially miss the opportunity to manage risks such as those in this case which may lead to death. 3, That doctors at SGH need training on the information available on HIE and how to access it. 4. That NHS South West London Integrated Care Board has made no formal provision for psychiatric liaison cover at QMH, despite there being such a clear clinical need for this that the team from psychiatric liaison have felt compelled to provide informal telephone advice for the last 10 years. 5. That the lack of formal psychiatric advice availability at QMH puts vulnerable patients at increased risk, since the only way to properly access such advice is for them to be sent by LAS ambulance to A&E at SGH, when they are physically frail, given that QMH is a rehabilitation unit.
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, 2023-0139
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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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