Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate out-of-hours psychiatric response and unsuitable section 136 suite
The earlier warning
Roberto Bottello · 16 Feb 2024 · Fiona Wilcox, Inner West London
“That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.”
judiciary.uk/…/roberto-bettello-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Roberto Bottello (16 Feb 2024) · stated timescale: none stated
“Concern number 6 - Psychiatric liaison nurses and psychiatric liaison doctors should have regard to diagnoses made by other doctors”
What recurred
- 23 Oct 2024 · Declan Morrison · Simon Milburn · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Roberto Bottello · 16 Feb 2024
“That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.”
Later · Declan Morrison · 23 Oct 2024
“The Section 136 Suite was completely inappropriate. [the deceased]'s mental health and behaviour declined further and ultimately this resulted in his death.”
What happened next
No web check of the stated actions has been published for this chain.