“During the course of the evidence from both family and medical witnesses it became clear…”

The coroner’s concerns

– During the course of the evidence from both family and medical witnesses it became clear that there were no adequate systems in place for providing crisis support to patients over the age of 65. The family were very concerned and very frustrated by the futile attempts they made to secure psychiatric input and support when they could see a rapidly deteriorating picture. There was no explanation as to why individuals in crisis who were 65 or under had access to the crisis service but once a person is over 65 that service is no longer available to them. It is not clear whether access to such services would have altered the outcome but the current structure and services available in my view denied Ms Guest with the opportunity of obtaining specialist assessment support at a much earlier stage. A further concern was that the GP surgery provides patients with the crisis number seemingly without appreciating that this would only be available to those who were 65 or under. Furthermore, the family's evidence was that when they called 101 seeking medical input and support for Ms Guest, they were told they would be referred to the crisis team but as soon as Ms Guest's age was mentioned they halted that process and said that they would not be able to refer her after all because of her age. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, and have the power to take such action and I invite you to give consideration to the following:. 1. Review of the crisis provisions as a whole, 2. Review of crisis services for those aged over 65 years, 3. Consideration of the accuracy of information disseminated to general practitioners so they are clear as to the nature and extent of any support services available to patients via your organisation.. 4. If you consider any changes are necessary to bridge the gap with regard to crisis support availability for those over 65, consideration of any stakeholders, such as 101, you find should be notified of any change in services available.

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, 2024-0493

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0