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recurance

Dean Ford

4 Dec 2024 · Coroner Nadia Persaud · East London

The coroner's concerns

  1. 1. lack of holistic risk formulation

    “Despite clear guidance from NICE in September 2022 relating to the need for a holistic formulation of risk to self, two NELFT teams involved in Mr [name redacted] crisis care failed to carry out a holistic formulation of the risk he posed to himself.”
  2. 2. simplistic risk assessment

    “A clinical lead for the mental health and wellbeing team within NELFT, gave evidence at the inquest in December 2024 that Mr [name redacted] risk was deemed to be low because”
  3. 3. lack of audit for rejected referrals

    “The Trust carries out risk assessment audits for clients who are accepted into the mental health and wellbeing team. There are no audits into the risk assessments for those persons who are referred to the team, but not accepted by the team.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Dean Ford · Recurance