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recurance

Inadequate discharge medication risk assessment

Closely relatedConfidence 0.80 · moderate2 reports · 2019–2023No published response to an earlier report One-page brief (print or PDF)

Greater Manchester Mental Health NHS Foundation Trust received 2 coroners' reports about this hazard between 24 Jul 2019 and 25 Sept 2023.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

No published response from Greater Manchester Mental Health NHS Foundation Trust was found for the earlier reports.

2
reports
2
different coroners
2019–2023
years
0.80
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Hannah Bharaj↗

    24 Jul 2019 · Alison Mutch · Manchester (South)

    “There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU.”
    Original on judiciary.uk ↗

    No published response from Greater Manchester Mental Health NHS Foundation Trust was found for this report.

  2. 4 years 2 months later

    Raised again · 1st time

    Shaun Houghton↗

    25 Sept 2023 · Alan Walsh · Manchester West

    Closely relatedConfidence 0.80 · moderatea different coroner
    “No medication was prescribed or dispensed to the Deceased at the time of self-discharge.”
    Original on judiciary.uk ↗

    Greater Manchester Mental Health NHS Foundation Trust responded.Response (PDF) ↗

  3. All reports to Greater Manchester Mental Health NHS Foundation Trust

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error