Linda Banks
19 Dec 2023 · Coroner Janine Richards · County Durham and Darlington
The coroner's concerns
1. ineffective implementation of mental health service improvements
“any actions taken as a result of the thematic review were not effective in implementing change and that the action plan was still a”
2. delayed serious incident investigations
“The Serious Incident Investigation into the care received by [the deceased] was not completed until the end of January 2023, some 9 months after the death”
3. loss of fresh evidence in investigations
“the quality of the investigation is severely compromised as the evidence is not captured when memories are fresh”
4. delayed implementation of safety improvements
“because any lessons to be learnt and improvements to be made to improve patient safety cannot be implemented promptly”