“The generic, tick-box style of history recording by CATT which does not paint a full and…”

The coroner’s concerns

1. The generic, tick-box style of history recording by CATT which does not paint a full and proper picture of the mental health of the patient, especially compared to the assessments of psychiatric liaison, are such that risk may be unrecorded and under appreciated by CATT and patients thus be put at risk. 2. That the role of CATT to look for alternatives to admission may risk CATT discharging patients who would benefit from admission and risk the repeat of making treatment plans that had recently failed such as in this case. Rather than looking for admission alternatives being a core function, should CATT rather better be focussed on the best treatment plan for the individual patient and thus admission being viewed as a clear option where appropriate rather a last resort, as it often appears to be presented in such cases before the coroner? 3. That the provision of care-coordinators be increased and improved so that patients who require them have ready access at the time of need and are not placed on a waiting list. 4. That patients to be discharged by CATT, as well as patients to be admitted are discussed with the on-call psychiatrist so that plans may be reviewed, and thus the risk of not admitting patients who would benefit from and/ or require admission such as Mr Khala, are less likely to be discharged inappropriately. 5. That where psychiatric teams differ in their assessments such as CATT and psychiatric liaison, as occurred here, patients are not discharged until opinion is sort from the on-call consultant and re-discussion taken place between those with differing views. 6. That expertise covering neurodevelopmental disorders such as ASD and ADHD is available as part of MINT.

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, 2023-0231

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