“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. The nationally set time from initial contact with the Crisis Team to some form of assessment is 4 hours. I heard evidence that achievement of this target in every case is not realised. It is of concern that timely assessment and treatment of person undergoing mental health crisis should be assessed as speedily as possible and within the set time period. Regulation 28 – After Inquest Document Template Updated 30/07/2021 2. The Triage Tool was explained in evidence to be essential in ensuring the patient received the correct treatment/service and is to be undertaken every time a patient contacts the Crisis Team. I was informed there was an aspiration to achieve completion of the Triage Tool every time, but it is not being completed on every occasion. It is of concern that such a key document which identifies risk, care and other matters is not completed on every occasion as it is mandated to be done. 3. In relation to making safeguarding referrals for children, the evidence I heard was in this particular case a referral should have been made and was not. I was told training had been undertaken to make all staff aware of what action to take. However, I was told in the majority of occasions it was believed a referral would be made. It is of concern in terms of protecting children that I was not satisfied that a referral was made in all situations that warranted such a referral. 4. I was told in evidence that a Safety Plan which is complied with input from the patient, their families and practitioners did not exist in Mr STOUT's case. I was told it is crucial document for identifying risks and ways to mitigate them. I was also told work was commenced by your organisation in December 2020 to ensure full and complete compliance with this requirement, but I was not reassured there was such compliance with the completion of Safety Plans in all cases at this time.

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, 2023-0300

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