“Matter 1 1”

The coroner’s concerns

– Matter 1 1. I heard evidence that there was a 6-day delay in the Community Mental Health Team team making a referral to the Home Treatment Team which was put down "clinical pressures". Upon discussion, these "clinical pressures" related to staffing levels and the evidence was that at the time the team was meant to have 7 clinical members of staff but only had 3. I was told that matters have improved somewhat and that now there is sufficient staffing levels. 2. However, it was confirmed that gaps in staffing levels do occur which can have a knock-on effect of causing issues with service delivery and care for patients. 3. It is not difficult to foresee that inadequate staffing levels will give rise to missed opportunities for patients to be assessed; for interventions to take place; and for treatments to be given - particularly where patients may choose to disengage with services but who do not demonstrate any "red flags" or early warnings, as was the case with Shelley. 4. As such, I am concerned about the risk of future deaths occurring if staffing issues arise in the future. Matter 2 1. I heard evidence from the Structured Judgment Review that a learning point was identified that early warning signs were not completed to the required expectation or standard. 2. As such, an Action Plan was prepared and a task was agreed that this would be discussed at the Trust Risk and Task Finishing Group to establish clear clinical standards, with the same then being disseminated within the Trust. This was allocated to the Clinical Service Manager for ICCR and was due to be completed by May 2024. 3. In evidence, it was confirmed that target had been missed due to a meeting being cancelled, but assurance was offered that it would take place in July - after the inquest has concluded. 4. I am concerned that if this target is pushed back and/or is not met, for whatever reason, there is a risk that future deaths will occur. Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced. It is for you and your organisation to take the action that is required to resolve the issues and to prevent future patients from dying avoidable deaths. It is not for me as Coroner to make recommendations on how you do that, therefore I leave matters in your hands.

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, 2024-0332

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