“is as follows: I am concerned that in cases where an individual is receiving treatment…”
Dated 18 May 2023, from the coroner for Swansea Neath and Port Talbot. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 13 Jul 2023.
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; a reply may have been sent and not yet published.
- Report dated18 May 2023
- Deadline13 Jul 2023
- Published on judiciary.uk19 May 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Swansea Bay University Health Board | Response publishedPublished on judiciary.uk in May 2023. |
The coroner’s concerns
is as follows: I am concerned that in cases where an individual is receiving treatment from alcohol and drug addiction services and treatment from the primary community mental health team that neither team is able to access the other teams records electronically. The lack of integrated electronic records between treating team means that important information regarding patient safety is not easily accessible between treating teams. Treating teams are reliant on referral letters which are necessarily limited and not always sufficient to capture all the detailed information available to a referring team. This is particularly concerning where there is dual diagnosis - such as substance misuse and mental health - given these are often complex cases. This is particularly the case where complex cases have not been referred into secondary mental health services and so do not have access to a care-coordinator who can oversee and understand the views of the various professionals treating and assisting an individual. 6 I am concerned that the lack of such an integrated electronic system of medical and treatment records inhibits the effective sharing of information regarding patient safety and so increases the risk that information of significance regarding a risk to life will be lost between agencies and not sufficiently understood between all those managing risk.
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, 2023-0163
- Added to Minute Book
- 8 Oct 2026
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- 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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