“I am concerned that the jury have found that the risk assesments and risk planning for…”

The coroner’s concerns

– 1. I am concerned that the jury have found that the risk assesments and risk planning for Carl’s s.17 leave in March 2023 was inadequate. This issue was not addressed in the Trusts’ internal investigation conducted by and I have not received any evidence that there have been reflections or changes following Carl’s deathon this issue to reassure me that there is not a continuing risk of future deaths. 2. I am concerned that the Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his motherwho outlined her concerns. 3. The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of nonprescriptionmedication and illicit substance misuse. 4. The Trust’s own review concluded that the clinical team could have sought to understand these risk factors through direct contact with Carl. 5. The Trusts own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family. The review concluded that the nursing team could have escalated this information via the on-call system for further medical support. 6. The review concluded that a risk to Carl’s physical health was present especially in view of research and evidence for substance misusers starting to use again after periods of abstaining. 7. I am concerned that on the 9th March, Carl should have been seen 2 face to face by the CMHT, in line with Trust Policy. Instead he only received a telephone call from a duty worker who had never met him. 8. I am concerned that prior to his commencing leave on the 7th March, Carl had not been allocated a CMHT Care Coordinator, despite being an inpatient for over 3 months, since 31st December 2021. 9. 6 gave evidence that although the Trust Review had identified a number of missed opportunites, the Trust Action plan, which contained 6 Action points was still “In progess”. was not able to identify a single action point that had been completed to date.

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, 2023-0157

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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