Lynsey Dearden
18 Nov 2025 · Coroner Emma Serrano · Staffordshire and Stoke on Trent
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of allocated psychiatric nurse appointments
“Evidence emerged during the inquest that Mrs [name redacted] was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place”
2. absence of standard assessment framework for psychiatric nurse
“Evidence emerged during the inquest that Mrs [name redacted] was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs [name redacted] may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role.”
This report
“Evidence emerged during the inquest that Mrs [name redacted] was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025.”