“When Michael was taken to St George’s Hospital, he explained that he had been back and…”
Dated 20 Oct 2023, from the coroner for Inner North London. 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 dated20 Oct 2023
- Deadline15 Dec 2023
- Published on judiciary.uk19 Dec 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South West London and St George's Mental Health NHS TrustNamed in the report as “South West London and St George’s Mental Health NHS Trust” | Response publishedPublished on judiciary.uk in December 2023. |
The coroner’s concerns
When Michael was taken to St George’s Hospital, he explained that he had been back and forth from the railway station, each He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen. In the meantime, it was not thought necessary to refer him to the crisis team. Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this. The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services. Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt. When you respond to this letter, I should be grateful to know not just what you have done to address the issue in your own trust, but also what you have done to raise national awareness.
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, 2023-0521
- 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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