Barnaby Aylward
14 Dec 2018 · Coroner John Broadbridge · West Yorkshire (West)
The coroner's concerns
1. heavy smoking and allowing clutter and waste to accumulate
“review those potential risks with a multi agency preventative approach and re assess those risks regularly over time”
2. lack of property inspections and assistance
“did not feel empowered to make property inspections regularly or at all and advise Mr [name redacted] and other agencies, or have sufficient resources at the right level to inspect and assist”
3. confidentiality issues between agencies
“may have been hampered by issues of confidentiality in communications between agencies”
4. absence of risk identification in care plan
“The mental health care delivered to Mr [name redacted] was within a Care Planning Approach. The Care Plan documentation did not identify his above behaviours in writing and thus potential risks, nor indicate review and solutions including with housing provision”
5. clutter not recognised as significant symptom
“The presence of clutter and thus risk was not always evidenced in other clinical notes as a symptom of Mr [name redacted] illness of significance as were other presentations of his illness”
6. limited family support for risk mitigation
“There was some but not much evidence of seeking to extend support to Mr [name redacted] through his family members including practical and financial help”