Anthony Preston
11 Aug 2016 · Coroner Robert Chapman · Rutland and North Leicestershire
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. living at home causing severe anxiety and depression
“Mr [name redacted] had demonstrated, in his early return from home leave in the first few days of November, that living at home was a source of substantial stress, and likely to cause him severe anxiety and deepen his depression.”
2. discharge system lacking robust documentation
“The system for discharge of patients, whereby a nurse makes contact with (in this case) the Leicestershire Crisis Team does not appear to have been robust. There was no documentary proof of the telephone call.”
3. lack of immediate follow up to notify discharge
“There was no immediate follow up by e mail or fax to the Crisis Team to notify the discharge, and the fact that Mr [name redacted] was at high risk because of the anxiety created when he was living at home.”
4. lack of support at high risk
“As aresult, Mr [name redacted] and his main carer | left without support at a time when he was at high risk”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“There are no systems, either in private practice or in the Priory Hospital, Altrincham to contact patients following a failure to attend appointments”
This report
“(3) There was no immediate follow up by e mail or fax to the Crisis Team to notify the discharge, and the fact that Mr [name redacted] was at high risk because of the anxiety created when he was living at home.”
Closely relatedConfidence 0.90 · high
This report
“(4) As aresult, Mr [name redacted] and his main carer | left without support at a time when he was at high risk.”
Later report
“Discharge Mr [name redacted] was discharged from the care of LPT on 3 December 2022, there was no planned support for Mr [name redacted] post-discharge other than some counselling which was due to start three weeks later.”
Responses
No published response was found on judiciary.uk.