“Evidence was heard that the mental health crisis staff do not appear to have appropriate…”

The coroner’s concerns

– (1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared. (2) The Operational Policy Mental Health Urgent Care Department pathways Appendices are not clear and do not appear to accord with the implementation. (3) Recent contact with the primary care mental health records did not appear to be accurately recorded in the System One Records with suicidal ideation not recorded. (4) Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1st June did not escalate Mr Bennett to the GP or Community Psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health. (5) Mr Bennett had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber. 2 (6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse. (7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison.

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, 2025-0089

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