Edward Lundy
21 Mar 2018 · Coroner Tony Williams · Somerset
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of continuity of care
“The South London and Maundsley NHS Foundation Trust ('The Trust') completed it's own Mental Health Investigation Re England Serious Incident Framework”
2. lack of documented family consultation
“The Trusts own findings identified a number of issues and a number of proposed actions”
3. lack of clear referral intent
“the doctor referring [the deceased] to the Lambeth Assessment and Liaison Team should have made it clear that he believed [the deceased] should be seen by a psychiatrist.”
Linked reports
Closely relatedConfidence 0.78 · moderate
Earlier report
“Communications between staff and family were haphazard the policy of involving family in care planning was not clear.”
This report
“That upon [the deceased]'s discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the tisks being explicitly discussed.”
Responses
No published response was found on judiciary.uk.