Annabel Findlay
1 Mar 2023 · Coroner Jake Taylor · Inner West London
The coroner's concerns
1. lack of contact with next of kin or emergency contacts
“Although a discharge plan was implemented in Ms. [name redacted] case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. [name redacted] being supported in the community upon discharge.”
2. lack of follow up appointment
“No follow up appointment was booked prior to Ms. [name redacted] discharge.”
3. lack of post discharge contact
“No attempt was made to contact Ms. [name redacted] until 6 September 2021 (some 10 days following her discharge).”