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recurance

Lee Grimes

26 Jul 2016 · Coroner Rachael Griffin · Manchester West

The coroner's concerns

  1. 1. failure to follow up overdose disclosures

    “During the inquest evidence was heard that: 1 i. Mr [name redacted] suffered with schizophrenia and was under the care of the Mental Health Services. Since 2004 he had been supported in the community by support workers from Next Stage which is a home health care service. They provided assistance to Mr [name redacted] on a daily basis, Monday to Friday. They would attend at his home address to assist him with basic activities and monitor his mental health. If there was a deterioration in his mental health they would”
  2. 2. lack of follow up on overdose disclosures

    “I have concerns with regard to the following: i. That no action was taken by an employee of Next Stage following Mr [name redacted]' disclosure of an overdose of medication on Thursday the 17th March. I have further concern that when action was taken on the Friday 18th March, a message was left for the Community Mental Health Team which was not followed up by Next Stage, or answered and actioned by the Community Mental Health Team. Although Mr [name redacted]' death was not as a result of an overdose, he did not”
  3. 3. inadequate referral processing to mental health team

    “I would also request that a review is carried out by 5 Boroughs Partnership of the policies and procedures in place regarding the processing of referrals to Wigan Recovery North given the fact that the message left by on the Friday morning was never acted upon, as if this were to happen again in the future I believe there could be a further death.”

Responses

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  • Nebius Token Factory inference
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  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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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Lee Grimes · Recurance