Claire Driver
24 Mar 2025 · Coroner Tanya Rawden · South Yorkshire West
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of engagement with mental health services
“there were only two attempts to see [the deceased] by the enhanced community mental health team between 28 November 2023, when she was seen in police custody, and 16 January 2024, when she was detained under the Mental Health Act, despite clear evidence her mental health was deteriorating”
2. inadequate staff training on substance misuse impact
“training on the effect of substance misuse on mental health conditions is not mandatory for all staff and would be of assistance when caring for patients such as [the deceased]”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Mr [name redacted] was passed between agencies without any lasting benefit.”
This report
“there were only two attempts to see [the deceased] by the enhanced community mental health team”
Identical hazardConfidence 0.90 · high
Earlier report
“There were no attempts by mental health services to speak to [the deceased] directly to properly and adequately assess his mental health condition.”
This report
“there were only two attempts to see [the deceased] by the enhanced community mental health team between 28 November 2023, when she was seen in”
Responses
2025-0161-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust.pdf ↗· South West Yorkshire Partnership NHS Foundation Trust
Stated action · July 2024
“A new initiative of Integrated Co-occurring Needs (ICoN) is being set up in Barnsley that will bring together co-located workers from substance misuse services, mental health services and social care services to work with people with co-existing mental health and substance misuse issues.”