Christopher Vickers
29 Feb 2024 · Coroner Leila Benyounes · Gateshead and South Tyneside
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of coordination of care
“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk”
2. lack of safeguarding referrals
“There were multiple repeated missed opportunities to make safeguarding referrals for formal safeguarding supervision from the safeguarding adult public protection team despite known escalating risk to self and to others”
3. risk of future deaths
“There remains a risk that future deaths could occur as the missed opportunities were significant and multiple and relate to clear processes and policies that were not followed”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.”
This report
“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.”
Closely relatedConfidence 0.90 · high
Earlier report
“- the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;”
This report
“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.”