“That Adrian, despite being a complex patient with multiple psychiatric diagnoses and at…”
Dated 7 Mar 2024, from the coroner for Inner West London. Sent to 2 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 2 May 2024.
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 dated7 Mar 2024
- Deadline2 May 2024
- Published on judiciary.uk14 Mar 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Central and North West London NHS Foundation Trust | Response publishedPublished on judiciary.uk in March 2024. |
| NHS England | Response publishedPublished on judiciary.uk in March 2024. |
The coroner’s concerns
1. That Adrian, despite being a complex patient with multiple psychiatric diagnoses and at high risk of impulsive behaviour and suicide was not seen nor assessed by a consultant either prior to starting psychological therapy or when he deteriorated. 2. That no pro-active care was considered for Adrian whilst he was in obvious mental health crisis in the last 17 days of his life. 3. That insufficient consideration appeared to have been given to the risk of impulsive suicide with instead assessment focussing on his denial of increased active suicidal intent. 4. That no follow up call or assessment was made to Adrian when his treatment session was interrupted by police attendence, and the treatment call was cut off. 5. That there were inadequate communications between the PCN MDT and those providing the psychological treatment.
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, 2024-0128
- 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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