Kieran Lavin
1 Aug 2024 · Coroner James Bennett · Birmingham and Solihull
The coroner's concerns
1. critical suicide risk information not recorded
“Critical suicide risk information was not recorded at all or not recorded in a timely manner”
2. inadequate risk assessment for informal patient transport
“Post-death trust learning led to new guidance for when an informal patient requests family, carer, or friend transport them from PDU”
3. inadequate risk assessment for informal patient transport
“I am not persuaded this is sufficient to remove the risk of an inadequate risk assessment in the future”