“For the Priory - DORKING 1”

The coroner’s concerns

For the Priory - DORKING 1. 2. 3. 4. 5. 6. 7. The Incident Review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge. There was no engagement prior to discharge with the local Home Based Treatment Team. There was no consultation with the Consultants who had treated Mr Thompson at the Priory in Altrincham only a few weeks earlier. There was no 48 hour follow up call to Mr Thompson following his discharge, as per Priory Policy. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided. There was no evidence that the four standard care plans had been opened during Mr Thompsons inpatient stay. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out. There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure. Nor was consideration given to whether any individuals should be reported to their regulatory body. For the Priory - ALTRINCHAM 1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly. 2. At the time of his appointment in January 2024 Mr Thompson was not under any NHS community services such as the home based treatment team. This was not recognised or known when formulating his ongoing plan. 3. No internal review was undertaken of Mr Thompsons admission within the Priory Altrincham to consider whether there was any learning For All: 1. There was a complete absence of any Consultant – Consultant discussions or communication, given this patient was receiving care from both the NHS and privately.

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, 2024-0443

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