Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of allocated care coordinator and psychiatric nurse appointments
The earlier warning
Rebecca Pykett · 17 Jul 2021 · Emma Serrano, Stoke-on-Trent & North Staffordshire Coroner's Court
“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.”
judiciary.uk/…/rebecca-pykett-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Rebecca Pykett (17 Jul 2021) · stated timescale: October 31st 2021
“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”
judiciary.uk/…/2021-0264-Response-from-North-Staffordshire-Comb…
What recurred
- 18 Nov 2025 · Lynsey Dearden · Emma Serrano · Closely related · confidence 0.86 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.