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recurance

Lucy Jones

11 Jan 2023 · Coroner Caroline Saunders · Gwent

The coroner's concerns

  1. 1. delayed access to cognitive behavioural therapy

    “[the deceased] [name redacted] was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that [the deceased] was still waiting for CBT at the time of her death in March 2022.”
  2. 2. lack of follow up after consultant review

    “Following [the deceased]'s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, [the deceased] was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone on only 2 occasions and did not speak to [the deceased]. The CPN was apparently reassured by [the deceased]'s housemate, who had no concerns”

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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Lucy Jones · Recurance