Ben O'Hara
17 Mar 2021 · Coroner Mary Hassell · Inner North London
The coroner's concerns
1. lack of family contact permission
“None of the healthcare professionals who assessed or treated Mr [name redacted] in the period leading up to his death asked if he would give permission for his family to be contacted”
2. outdated alert on admission
“There was an alert on Mr [name redacted]'s medical record, saying that admission to hospital was unhelpful to him”
3. non formal assessment
“The review undertaken on 3 October was with a s12 approved doctor and an approved mental health professional, but was not a formal mental health assessment”
4. absence of care coordinator
“Mr [name redacted] did not have a care co-ordinator or other member of the community mental health team in overall charge of his care”