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recurance

Guy Robinson

12 Nov 2015 · Coroner Lisa Hashmi · Manchester (North)

The coroner's concerns

  1. 1. inappropriate timely application of AWOL protocol

    “The 'AWOL' protocol was not applied appropriately/in a timely manner and during the course of the evidence it became apparent that some of clinicians lacked familiarity with the protocol and process. Whilst the Trust has taken steps to ensure that the protocol has been discussed with all staff based on the ward in question, action has not been taken Trust-wide to ensure that all staff are fully familiar with this policy.”
  2. 2. lack of inpatient clinical psychology facility and direct referral pathway

    “Clinical Psychology Service - the only access afforded to a Clinical Psychologist depends upon three pre-requisites being met - i) discharge ii) to a fixed abode iii) onward referral by the Community Mental Health Team. There is no inpatient Clinical Psychology facility and no ability for hospital clinicians to refer a patient directly. This is a significant service gap and potentially prejudices/puts at risk some of the most vulnerable people e.g. those who are of no fixed abode.”

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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