Daniel Lee
21 Nov 2022 · Coroner Steve Eccleston · South Yorkshire West
The coroner's concerns
1. lack of key worker
“no one was taking responsibility for his care in a 'key worker' type role”
2. superficial risk assessments
“risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention”
3. lack of communication with armed forces
“failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it”
4. superficial family communication
“Communication with the family was superficial and the evidence was that their perception was that they couldn't fully share issues and concerns because of perceived barriers in information sharing”
5. inadequate risk sharing
“staff in the team struggled with decision making around information sharing”