Lack of allocated care coordinator and psychiatric nurse appointments

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2021 → 2025Lynsey Dearden4 years 4 months after Rebecca Pykett · same coronerClosely relatedConfidence 0.86 · high

  Closely relatedConfidence 0.86 · high

  Both reports highlight that patients are allocated a mental health worker but the allocated worker does not actually provide the expected care or appointments. The underlying issue is the absence of a reliable system or policy to ensure the allocated role is fulfilled.

  Rebecca Pykett · 17 Jul 2021

  “The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role.”

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  Lynsey Dearden · 18 Nov 2025

  “Evidence emerged during the inquest that Mrs [name redacted] was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025.”

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  Stated action in the response to the earlier report

  “The revised Trust Care Management Policy provides expectation in terms of the timeframes required for allocation, assessment, care planning and review (see appendix 1). Training for all Care Co-ordinators has taken place to ensure that staff are aware of the full requirements of their role. Assurance that this process is followed is monitored through the weekly review of compliance reports, overseen by Team Leaders. This data is further reviewed at Service Manager and Associate Director Level”

  Earlier report in the app · Later report in the app