Adam Gallagher
14 Sept 2022 · Coroner Karen Dilks · Newcastle and North Tyneside
The coroner's concerns
1. inadequate assessment of mental health crisis
“NEAS Trust confirmed in evidence that a more detailed assessment of AG should have been undertaken and Clinical input sought leading to Ambulance dispatch and potentially an 5 alternative outcome for AG”
2. inadequate staff training
“Comprehensive retraining is required for those directly involved”
3. inadequate policy review for mental health incidents
“An urgent review of Trust policy/protocol for handling/management of mental health related incidents should be undertaken and associated training in respect thereof”
4. lack of safeguard implementation
“Trust to review the events leading to AG's death and identify any additional safeguards they may put in place to prevent future deaths”
Responses
No published response was found on judiciary.uk.