“On 4 July 2022 Mr”

The coroner’s concerns

- (1) On 4 July 2022 Mr. Harper attended the Emergency Department at Gloucester Royal Hospital, and was seen by a nurse from the Mental Health Liaison team there, who recorded that he was very anxious and distressed, and voicing onaoina thouahts of suicide. The nurse felt that Mr. Haroer would benefit from a l period of treatment under the care of the Home Treatment Team, and because Mr. Harper was living in Worcestershire at the time, and because it was now in the early hours of the following day, he called the Worcestershire Crisis Team to arrange that. The nurse concerned was under the impression that by making this phone call, and passing on Mr. Harper's details to the Crisis Team, he was referring Mr. Harper's case to them. He told the inquest that he was expecting mental health services in Worcestershire to arrange a further urgent assessment of Mr. Harper, and he therefore ensured that Mr. Harper was told to expect the Crisis Team to contact him to arrange a further assessment. (2) The Clinical Lead for the Crisis Team in Worcestershire gave evidence to the inquest that whilst the Crisis Team did receive a request from the nurse at Gloucester that night, they interpreted it only as a request for further assessment ( but not an urgent one ), and not as a request that Mr. Harper be referred to the Home Treatment Team. (3) In the event, an urgent assessment was not arranged, and Mr. Harper's case was only considered by the Home Treatment Team in Worcestershire when his temporary GP in Worcestershire, out of further concern for Mr. Harper's mental health, made a new and separate referral to them. (4) I have concluded that the events described above arose out of a lack of understanding between the two N HS Trusts concerned ( Herefordshire & Worcestershire Health and Care NHS Trust ( HWHCT ) and Gloucestershire Health and Care NHS Trust ( GHCT ) ) as to how each other's mental health services are run - otherwise arrangements would have been made for Mr. Harper's mental health to be assessed urgently, as was intended. (5) If staff at HWHCT and GHCT do not understand how to make urgent mental health referrals or requests for urgent mental health assessments to each other, there remains a risk that other deaths may occur in similar circumstances in the 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, 2023-0179

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