“During the Inquest evidence was heard that: i”
Dated 25 Sep 2023, from the coroner for Manchester West. 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 publishedOrganisations 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 dated25 Sep 2023
- Deadline20 Nov 2023
- Published on judiciary.uk28 Nov 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Greater Manchester Mental Health NHS Foundation TrustNamed in the report as “Greater Manchester mental Health NHS Foundation Trust” | Response publishedPublished on judiciary.uk in November 2023. |
The coroner’s concerns
1. During the Inquest evidence was heard that: i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed. ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL. iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments. iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or longterm absences. 2. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews their procedures and policies to cover the absence of a Care Coordinator, both in relation to short term and long-term absences, and in relation to the appointment of an interim Care Coordinator. 3. I further request that the Trust reviews their procedures and policies in relation to the responsibility of a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments. 4. I further request that the Trust reviews the procedures and policies in relation to resilience plans to cover the absence of an appointed Care Coordinator. 3 4
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, 2023-0464
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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