Ethel Robertson
17 Nov 2025 · Coroner Nicholas Walker · Hampshire, Portsmouth and Southampton
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of notification of patient admission or discharge
“the service is not routinely informed when one of their patients is admitted to or discharged from ED”
2. lack of awareness of physical health crises affecting mental health
“OPMH will not know if one of their patients has had a physical health crisis which could precipitate a decline in their mental health”
3. burden on primary care to alert community teams
“places an added pressure on those in primary care to have systems in place to alert the community teams when they receive discharge documentation from ED”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity.”
This report
“If the presentation at the hospital was for a mental health related issue, then the OPMH team is likely notified as there will be contact with the psychiatric liaison service in the hospital.”