Drew Howe
15 May 2023 · Coroner Chris Morris · Manchester South
The coroner's concerns
1. lack of critical analysis of events
“The Trust's own investigation into events leading to Mr [name redacted] death did not consider the full extent of his contacts with mental health services, lacked any meaningful degree of critical analysis of events, and omitted to seek to explore fundamental issues such as access to services from the patient's perspective”