“I am concerned that the Home Treatment Team referred David to a service to receive…”

The coroner’s concerns

– 1. I am concerned that the Home Treatment Team referred David to a service to receive psychological/ talking therapies. This was then called Healthy Minds. This referral took place when the HTT discharged David as they considered him to be sufficiently ‘stable’ under their HTT definitions. 2. However, David was not accepted for by Healthy Minds because they had a policy that they would not accept referrals for indivduals who they did not consider to be sufficiently ‘stable’ under their Healthy Minds policies. 3. One of the criteria for stability was that the individual should not have attempted suicide or serious self-harm for 3 months. This was not known to the HTT at the time they made the referral. The effect of this policy meant that David was not accepted for this service, despite him making clear to services that talking therapies was what he needed most to support his mental health. 4. I heard evidence that this policy remains in place within NHS Talking Therapies (the successor to Healthy Minds), but is currently under review. I did not hear any evidence as to if or when it will change. 5. I am concerned that the lack of shared understanding and definition of ‘stablilty’ for patients along the talking therapies pathway creates a risk of future deaths. 6. I heard evidence that since David’s death, the HTT has emailed at the staff at the Tameside HTT to re-iterate the importance of referring cases to SPOE meetings for MDT consideration, and that this has been discussed in two team meetings before February 2024. There was no evidence before me of whether this has been embedded or audited within the team to reduce the risk of future deaths.

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, 2024-0499

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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