Edward Rhodes
1 Aug 2023 · Coroner Richard Middleton · Dorset
The coroner's concerns
1. breakdown in communication or misunderstanding between GP and patient
“There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral”
2. lack of automatic referral system after 90 day sobriety
“There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient”
3. absence of written confirmation of responsibilities
“There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient”