Mark Ravensdale
16 May 2023 · Coroner Abigail Combes · South Yorkshire (West District)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of direct contact with mental health services
“There were no attempts by mental health services to speak to [the deceased] directly to properly and adequately assess his mental health condition.”
2. ongoing mental health challenges
“[the deceased] had suffered with mental health conditions for a long period of time. Following one attempt to die by suicide he was placed into a care setting in order to support him before being moved into his own premises. He had a number of difficulties within that setting and continued to suffer with mental health challenges.”
3. discharge without assessment
“His GP referred him into mental health services for assessment however when the services made contact with the home he was residing in [the deceased] was not present at the home. The workers spoke to care staff but did not follow up with [the deceased] afterwards and discharged him without speaking to him at any point.”
4. suicide
“Shortly after this [the deceased] was found hanged and his death was by suicide.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“There were no attempts by mental health services to speak to [the deceased] directly to properly and adequately assess his mental health condition.”
Later report
“there were only two attempts to see [the deceased] by the enhanced community mental health team between 28 November 2023, when she was seen in”
Responses
2025-0400-Response-from-South-West-Yorkshire-Partnership-NHS-Trust.pdf ↗· South West Yorkshire Partnership NHS Foundation Trust
Stated action
“The Trust will therefore develop and implement a triage checklist in respect of the review's findings.”