“Out of hours and emergency mental health care for people who are not registered with an…”
Dated 16 Aug 2023, from the coroner for Milton Keynes. 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
All responses publishedReplies were due by 11 Oct 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 dated16 Aug 2023
- Deadline11 Oct 2023
- Published on judiciary.uk6 Sep 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North West London NHS Foundation Trust | Response publishedPublished on judiciary.uk in September 2023. |
| NHS Bedfordshire, Luton and Milton Keynes Integrated Care BoardNamed in the report as “BLMK Integrated Care Board” | Response publishedPublished on judiciary.uk in September 2023. |
| Red House Surgery | Response publishedPublished on judiciary.uk in September 2023. |
The coroner’s concerns
Out of hours and emergency mental health care for people who are not registered with an NHS GP in Milton Keynes may be obtained by attending the Emergency Department at the Milton Keynes University Hospital where mental health professionals are based. Through Kelvin's period of deteriorating mental health, which was obvious to those who knew him, his mother made repeated attempts to secure mental health assessment and care for him. She was not directed clearly by the professionals she did have contact with, to take him to the Emergency Department for assistance. There was a gap which Kelvin fell through and he did not receive either mental health assessment or care. It was not possible to say that the failure to receive assessment or care resulted in Kelvin attempting to take the lives of others and succeeding in taking the life of his male neighbour. It was clear that the lack of clear information and direction in regard to how to obtain that mental health assessment or care contributed to Kelvin not presenting for assessment which may possibly have averted the tragic events which unfolded on the 26th June 2021. This in turn raises the prospect that others, in similar predicaments may also be unable to obtain the care required.
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, 2023-0296
- 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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